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A. TEEATISE 



ON 



YESICO-VAGINAL FISTULA 



IBY IVLSCHUPPEET, iM. D., 

SURGEON OF THE ORTHOPJEDIC INSTITUTE AT NEW ORLEANS, LOUISIANA, 
UNITED STATES OF AMERICA. 



NEW ORLEANS: 

DAILY COMMERCIAL BULLETIN PRINT. 

1866. 

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Entered, according to Act of Congress, in the year 18G6, by M. Schuppert, in the Clerk's Office of the District Court of the 

United States, for the Eastern District of Louisiana. 



The operation of Vesico- Vaginal Fistula is illustrated by seventeen cases. The 
curative treatment includes two obliterations of the. vagina, one of which was obtained 
by the method known under the name of Episiorraphy, being the only case on record 
where this method has been crowned with a perfect success. Annexed is a critical review 
of the history of the operation of vesico-vaginal fistula in France, Germany, England and 
America. 

It will be proper to remark here, that the greater part of this treatise has been in 
manuscript since 1860. 



TO 
ALEXANDER II, 

CZAR OF ALL THE RUSSIAS, 

The great Liberator of the Nineteenth Century; 

Whose gigantic strides in the cause of human liberty, scientific attainments, 

And liberal appreciation of all that tends towards the overthrow of prejudice and the 

Welfare of Mankind, 

Challenges the admiration of the World, 

This Treatise is respectfully dedicated, 

BY 

THE AUTHOR. 



VESICOVAGINAL FISTULA 



' - •» ' 



A. Definition — Causes — Operation — After-Treatment. 

B. Cases. 

C. History of the Operation. 



.-•♦— . 



A. Definition. — Vesico- vaginal fistula is 
an affliction in which the vagina has become 
the excretory duct of the bladder ; or in which 
the urethral aperture is transferred to the 
anterior wall of the vagina ; a condition 
which places the sufferer, too often, liors de 
societe, and condemns her to the utmost 
wretchedness ; but this definition does not 
exhaust the subject. Let me, therefore, copy 
a picture drawn by the great Dieffenbach, so 
true, so precise, so terribly beautiful: "A 
vesico-vaginal fistula," he says, "is the great- 
est misfortune that can happen to a woman, 
and the more so, because she is condemned 
to Live with it, without the hope to die from 
it ; to submit to all the sequelae of its tortures 
till she succumbs either to another disease or 
to old age. There is not a more pitiable con- 
dition than that of a woman suffering from a 
vesico-vaginal fistula. The urine constantly 
flowing into the vagina, and partially retain- 
ed there and heated, runs down the labia, 
perina?um, and over the nates and thighs, 
producing a most intolerable stench. The 
skin of these parts becomes inflamed and 
covered by a pustulous eruption. An insup- 
portable itching and burning sensation tor- 
tures the patient, so much so, that she 
scratches the skin to bleeding. Many tear 
the incrustated hair out of the pudendal 
parts, calling on death to relieve them from 
their suffering. The comfort of a clean shift 



is unknown to them ; it is soiled as soon as 
put on ; a comfortable bed, that grave for 
all sorrows and afflictions, is not their lot, 
for it will soon be drenched with urine. Many 
of the wealthier classes are, therefore, con- 
demned for ever to the straw. The air of the 
room of the unfortunate woman nauseates 
the visitor and drives him off. All family 
ties are torn asunder by this terrible disease. 
The husband has an aversion for his own wife ; 
the tender mother is exiled from the circle oi 
her own children. She sits, solitary and alone 
in the cold, on a perforated chair. This is 
not fiction, but naked truth ; and the cure for 
snch an evil is the prize for which we labor." 

These unfortunate women must ever be the 
subjects of our deepest sympathy ; but it is 
not only philanthropy which induces the 
surgeon to be so indefatigable in his endeav- 
ors to close a fistulous opening in the bladder, 
to free the wretched from their suffering, 
their despondency, their banishment; it 
equally springs from an ambition to over- 
come difficulties or obstacles thought to be 
insurmounta ble . 

Causes. — In the majority of instances a 
vesico-vaginal fistula originates through the 
mortification of a portion of the vagina and 
bladder, in consequence of these parts being 
compressed by an impacted portion of tin 
foetis, the head or breech pressing against 
the os pubis, thus preventing the circulation 



8 



M. Schtjppert on Yesico-Yaginal Fistula. 



of the blood in the tissues involved. Morti- 
fication may occur during a short as well as 
a protracted labor. The sloughing of the 
mortified parts may take place before the 
foetus is born, a few hours or days afterwards, 
or it may happen at a still later period (the 
case of Adler, Iowa, 29 days after delivery, 
when the slough was only partially sepa- 
rated) 

In the majority of cases the injury happens 
at the first labor, though it is not uncommon 
to meet with cases where children have been 
born previously without causing any injury 
of this character. 

Amongst other causes of the origin of this 
disease, we find the following mentioned : 
Stone in the bladder during parturition (I. 
B. Brown lias reported such a case, and I 
think Case V in the sequel will be found to 
be another illustration); or this accident may 
follow an operation for stone (Case V), or 
attend extending cancer of the uterus to the 
vagina and bladder; syphilitic ulcers ; inju- 
ries caused by pessaries ; accidental injuries, 
and amonst these the " unskillful use of the 
forceps" " the rash attempts of the practitioner 
to deliver the foetus by instruments'" (Liston). 

If, at the last moment, a physician is called 
upon after days of labor-pain have been en- 
dured by the unrelieved sufferer, and the 
practitioner finds the use of the forceps ne- 
cessary, and a fistula should afterwards be- 
come established, all the ignorant, and their 
name is legion, at once lay the blame at the 
door of the physician. I, for my part, have 
no patience with such unfounded accusa- 
tions, and those who are loudest in blaming 
others, wovdd talk quite differently if the 
case had happened to themselves. If there 
is any blame to be imputed in the matter, let 
it rest with those who call for assistance when 
too late. I emphatically deny the charge 
that forceps cause fistula, and I will be sup- 
ported by the majority of physicians, as well 
as by the fact, that a scrupulous examina- 
tion into the history of these injuries will 
reveal that in most of them, no instrument 



had been used at all, or if used, had been at 
a period when the presumption was strong 
that mortification had already taken place. 
If " the rash attempts of practitioners to 
deliver by means of instruments " had any 
foundation in fact, how is it to be explained 
that the statistical reports of the lying-in 
hospitals in Germany seldom refer to such 
cases 1 There is no other explanation of the 
fact, and I speak from experience, except in 
the early application of the forceps, which are 
used in extenso for the instruction of the stu- 
dents ; while, according to the theorists, just 
the reverse ought to be the case. But we often 
see objects through the warm medium of our 
own imagination, that are not strictly war- 
ranted by facts. 

Simultaneously with the appearance of the 
fistula, the discharge of urine by the natural 
outlet ceases, and, in most instances, an entire 
cessation of the catamenia follows ; though it 
is occasionally found to be uninterrupted. 

Operation. — The operation for the relief 
of vesico-vaginal fistula ought to be under- 
taken as soon as the fistulous opening be- 
comes stationary, and its edges cicatrized. 
A woman recently delivered, or with milk 
still in her breast, should not be operated 
upon. It has been observed that several 
women so operated upon have died in conse- 
quence of this otherwise harmless operation. 

The Materials Employed. — The apparatus 
for operating in this class of diseases con- 
sists of — 

1st. A double lever speculum [fig. 1] called 
the duck-bill speculum (Sims), made of brass, 
galvanized with silver and polished to reflect 
sufficient light upon the parts operated upon. 
This speculum will not fatigue the assistant, 
if grasped with the full hand in the centre, 
having one branch resting on the dorsum of 
the hand, which is placed on the lower part 
of the sacrum of the patient. 

2d. A sharp hook [fig. 2] for taking hold 
of the edges of the fistula, in order to be 
vivified. 



M. SoiiurrEKT on Vesico-Vaginal Fistula. 



9 



3d. One or two straight knives [fig-. 3] to 
pare oft' the borders. 

4th. A needle fixed in a handle [fig. 1], the 
stem of the needle to he l.d mn thick and 9 cm 
long ; made of iron, so that it can be bent; 
the point of steel, l cm in length, spear-shaped, 
and with an eve sufficiently large to take up 
the silver wire. (Such a needle has answered 
me in all eases in which the sewing was done 
anterio-posteriorly.) 

oth. A curved needle [fig. 5], to be used 
when the sutures have to be applied in the 
long axis of the vagina. 

6th. A blunt hook [fig. C] for directing 
the point of the needle, when through the 
walls of the fistula. 

7th. A pair of forceps to carry the thread 
into the eye of the needle. 

8th. Two pair of scissors, a straight one 
to clip the wire Avith, and another one curved 
over its plates. This latter one is often used 
with benefit in cutting off portions of the 
mucous membrane of the borders. 

9th. A suture adjuster [fig. 7] (Bozeman's 
modified). 

10th. A wire twister [fig. 8] (CogshiU's). 

11th. A collection of silver catheters 
[fig. 9]. 

12th. A silver wire of 0.5 mm in diameter. 
The best and purest material is obtained by 
melting chloride of silver. 

Position of the Patient. — Two positions 
have been advocated — 1st, on knees and el- 
bows ; 2d, on one side, the left being prefer- 
red (Sims). The most convenient of the two 
for the patient, and I think she deserves 
some consideration, is the latter one. It is, 
besides, the best in which to administer 
chloroform. After a purgative has been 
given, the day previous to the operation, to 
evacuate the bowels, the patient is place J. on 
a table and mattress covered with oil cloth, 
which is large enough to hang down into a 
bucket for the reception of the water which 
is injected into the vagina during the opera- 
tion. Supporting the head of the patient 
with pillows, she is brought near the end of 



the table, her thighs bent to a right angle 
with her body. The speculum is then intro- 
duced into the vagina and held by an assist- 
ant. It is advisable to operate on a sunny 
day, and to place the patient so that the sun 
will shine iuto the speculum, when, by the 
reflected light, the parts operated upon will 
be most favorably shown. 

Paring the borders of the Fistula. — This is 
executed by holding up, with a sharp hook, 
those parts of the mucous membrane of the 
fistulous borders which are to be removed. 
The edges must be denuded to the extent, if 
possible, of 10 ram , including the border of the 
mucous membrane of the bladder. With 
fistulas, where the long axis runs in a trans- 
verse or oblique direction, and this, accord- 
ing to my experience, occurs in a majority 
of cases, I am in the habit of cutting first 
around the loicer margin to the full extent 
that the mucous membrane should be remo- 
ved. By taking this course, the operator will 
not suffer any obstruction of the parts ope- 
rated upon by blood, which would happen if 
the upper border was first pared off*. In 
cases where the bladder is inverted and pro- 
truding, a circumstance not uncommon in 
large fistulas, the best method to keep it out 
of the way, is by introducing sponges through 
the fistulous opening into the bladder. This 
will also have the effect of elevating and dis- 
tending the edges, and do away with the great 
difficulty experienced by some surgeons in 
denuding the edges of the fistula. The time 
of operation Avill be much shortened by em- 
ploying an assistant to syringe the bleeding 
parts with cold water, whilst the edges are 
denuded. Success depends, in the main, on 
the proper execution of this the most essen- 
tial part of the operation, viz: in properly 
denuding the parts to be brought in contact. 
Application of the sutures and co-aptation 
of the edges of the wound. — The needle is uoav 
entered outside the lower border of the 
AA r ound, and pushed through its Avhole thick- 
ness ; re-entered in the upper margin from 
inside the bladder, being thrust equally 



10 



M. Schuppert on Vesico-Vaginal Fistula. 



through, its walls so as to come out above the 
denudation. As soon as the point of the 
needle appears here, the blunt hook is 
brought behind it, and, by pressing it against 
the vagina, the needle is thrust through with 
facility, until its eye is visible. Hooking now 
the point of the needle below the eye to- 
wards the operator, the silver wire is easily 
introduced in the eye by a steady hand, or 
with the aid of forceps. When the wire is 
located in the needle, the latter is withdrawn, 
and the wire will bend and follow. This 
mode of sewing is so simple, that whoever 
tries it once will give up all other contri- 
vances. It is obvious that this needle can 
only be used in fistulas with the long axis 
running in a transverse or oblique direction, 
where also the edges are united anterio-pos- 
teriorly. In cases where the sutures should 
be applied in the long axis of the vagina, the 
curved needle will be brought in use. The 
sutures are placed 4 mm distant from each 
other. The length of each silver wire de- 
pends upon the depth at which the fistula is 
located. It must be of sufficient length that 
a hold of it can be obtained outside the 
vagina, after the loop has been formed. 

In giving the above direction for pushing 
the needle through the whole wall of the fistu- 
lous borders, I am aware of having only a few 
surgeons on my side, but my best advocate 
is the success of my operations. The objec- 
tions raised against it are mostly based on 
hypothetical speculations, mere theories, 
without corroboration by facts. The fear of 
wounding the mucous membrane of the 
bladder is a spectre* not founded in reality. 
While some do not hesitate to cut off the 
borders of its mueous membrane, yet they 
fear the puncture of a needle, not knowing 
how many times they have unconsciously 
caused it. In my operations I have invaria- 
bly thrust the needle through both walls of 
the fistula, in all making one hundred and 
ninety needle tvotinds of the bladder, and yet 
not a single bad result has followed — not one 
new fistulous opening was thereby produced ! 



This does not speak much in favor of the 
theories advanced by the opponents of this 
course. Not only do I deny the allegations 
concerning the bad results which are said to 
be occasioned by wounds of the vesical mu- 
cous membrane ; but further, I do firmly be- 
lieve, that a great deal of the success I have 
obtained in operations of this character, is 
justly due to this very cause, viz : that I have 
taken up the bladder in the sutures. 

As soon as the sutures are applied, the 
edges of the wound are co-aptated by the 
use of the suture-adjuster. Catching both 
threads of each suture by the slice of the 
instrument, and sliding the latter down to 
the fistulous edges whilst holding the ends of 
the suture in the left hand, the denuded sur- 
face of the borders is brought in co-aptation 
and the firmness of the wire will prevent 
them from re-opening. The edges to be 
brought together must be under no tension. 
Should this happen, then lateral incisions 
through the mucous membrane of the vagina 
on one or both sides of the fistulous opening 
are, under the circumstances, the best means 
in our power to prevent it. The idea is Dief- 
fenbach's ; though failing in most of his ope- 
rations for the cure of these fistulas, he has 
equally failed to establish its value. I have 
given these lateral incisions a fair trial, and 
can not help assigning them a prominent 
place in the success I have met with in oblit- 
erating fistidas of great extent by one opera- 
tion. Should it happen that in co-aptating 
the edges, portions of the mucous membrane 
of the bladder should come forward, a cathe- 
ter carried through the urethra and held by 
an assistant will keep them out of the way. 
After the sutures are properly adjusted they 
will then be twisted three or four times, which 
may be accomplished either by the fingers or 
CogshilPs twister. The sutures will then be 
cut off above the twist. 

Some surgeons say that the edges must 
not be united before bleeding has been ar- 
rested, to accomplish which, pressure, ice, 
and time have been recommended, The best 



M. Schuppert on Vesicovaginal Fistula, 



11 



method to arrest bleeding, according to my 
experience, consists in tying the sutures, and 
I never hare had cause to repent having 
doue so. 

In my earlier operations I was in the habit 
of giving preference to the method of Boze- 
man, so highly recommended by its distin- 
guished inventor. I have operated success- 
fully with it, yet, in using the interrupted 
twisted suture I have met with the same 
success. I have applied the button and 
twisted suture combined, simultaneously in 
the same case, and both methods have proved 
to be equally good. If I give preference to 
the interrupted twisted suture, I do it from 
no other reason than that it is more simple 
in its application. Wherever the wire-loops 
are too much tightened, be it by using the 
button or the twisted suture, the wire will 
cut into the tissue. And why should it be 
otherwise ? I have given the silver wire 
sutures a very extensive application, using 
them for years in nearly every kind of ope- 
ration where sutures were required. The 
result has invariably proved that whenever 
the sutures were drawn very tight, or the 
parts united under any tension, that the wire 
cut into the tissues. It is the maximum of 
absurdity to claim for the silver wire an 
exception from physical laws. "What holds 
good in that respect for organic substances, 
like silk or hemp thread, holds equally good 
for metallic wire, whether it be lead, iron, 
gold or silver. 

The preference given to metallic sutures is 
based upon its entire innocuousness when 
imbedded in animal tissue ; which can not be 
said of sutures made from organic matter. 
The latter are liable to be imbibed with 
urine and blood by capillary attraction, which 
fluids, when decomposed, will give rise to sup- 
puration in the stitch-holes, and thereby cause 
new fistulas or render a cutting of the suture 
necessary. Silver is, next to gold, the most 
malleable and ductile of all metals, and this 
will make it the best material for sutures. 
Professor Simpson, of Edinburgh, who stands 



on the iron platform, says, "I prefer the 
blue iron wire, because it is stronger, cheaper, 
and altogether more easily worked than sil- 
ver wire," In the latter part of his sentence 
Professor Siotpson is entirely wrong ; silver 
is more easily worked than iron. His other 
reasons are no better. A silver wire of 0.5 mm 
diameter (which is the wire we use) will carry 
a weight of 10 pounds before it breaks, 
whilst an iron wire of the same diameter will 
hold a weight of 30 pounds. Iron is there- 
fore stronger than silver ; but does Professor 
Simpson intend to use, in tying a suture, a 
force sufficient to break even a silver wire 1 
In collecting the ends of each wire cut off 
and that portion which has served as the 
suture, nothing will be lost. In again melt- 
ing the pieces, nearly the whole weight of the 
silver, with the exception of a small quantity 
which might be lost in the melting process, 
will be obtained. The expense, therefore, 
incurred in using the " costly silver wire " 
would not, I think, bear hard on the pocket 
of the surgeon, even if he should be as poor 
as Lazarus. In the end " the best is always 
the cheapest." 

After- Treatment. — After the operation is 
finished, the patient should be transferred to 
a bed containing only a well-stuffed mattress, 
with an aperture in the centre, lined with an 
india rubber tube, of sufficient length to 
reach down to a bucket, placed beneath the 
bed for the collection of the urine as well as 
the water, with which the bladder is washed 
out by syringing. A catheter is then intro- 
duced through the urethra, and permanently 
lodged in the bladder, to prevent the accu- 
mulation of urine in it. The catheters I am 
using, and of which it is advisable to have a 
collection of different sizes and lengths on 
hand, are made from thin silver plate, with 
from three to four rows of holes in them. 
The diameter of the holes must not be larger 
than one millimetre, otherwise the mucous 
membrane of the neck of the bladder will be 
caught therein, causing a distressing pain to 
the patient when the catheter is removed. 



12 



M. Sciiuppeet on Vesico-Vaginal Fistula. 



The mouth of the catheter should contain a 
large flattened ring', to prevent the urine from 
running back on its outside. There should 
he, in addition, two rings opposite each other, 
through which a piece of tape is carried and 
fastened to a bandage across the abdomen — 
one end of the tape going over the nates and 
fastened on the back, the other in front. The 
catheter must be removed twice a day to 
clean it from the urinary deposits, which 
may be best accomplished by nitric acid so 
much diluted with water as not to dissolve 
the silver. I have been in the habit of or- 
dering injections with cold water every thirty 
minutes during the first forty-eight hours. 
The advantages gained by this mode of 
treatment are obvious. The patient will al- 
ways lie on a dry bed, can move at will from 
one side to the other, and the urine will 
under no circumstances accumulate in the 
bladder. 

To prevent the urine coming in contact 
with the wound has always been considered 
of great importance in the after-treatment, 
and a distinguished surgeon has gone so far 
as to propose the puncture of the bladder 
above the os pubis, and the introduction of 
a catheter to draw off the urine, besides re- 
commending the introduction of a catheter 
into the urethra every hour or two. But 
there is no lack of precisely the contrary 
opinion. Some do away entirely with the 
application of the catheter, confining the pa- 
tient only to bed. I have made a trial of 
doing away with both bed and catheter (vide 
Case XVII) with a successful result ; but I 
am not yet prepared to advance an opinion 
based upon a single fact, and to recommend, 
as some have done, the abolishment of that 
part of the after-treatment which has been 
considered as of the greatest import ; though 
it may prove in the end to be nothing but a 
great bugbear. The time of removing the 
sutures ought to be extended to ten or four- 
teen days. The innoeuousness of the wire in 
animal tissue should prevent the surgeon 
from removing the sutures earlier. I have 



observed in two of my cases, one on the sixth 
(Case VII), the other on the seventh day 
(Case IX) after the operation, that in inject- 
ing the bladder with water, some leaking 
occurred from a part of the co-aptated edges ; 
yet when the sutures were removed on the 
twelfth day, the fistulas were perfectly and 
permanently cured. 

The act of removing the sutures is simple ; 
while the twist is held by the forceps and a 
little raised, the loop is cut through with a 
pair of scissors, after which the sutures are 
pulled out. 

"A most important feature in the after- 
treatment," says Professor Simpson, of Edin- 
burgh, " is the constant administration of 
such doses of opium or morphia as shall suf- 
fice to keep the patient fully under its influ- 
ence. It fulfils," says this distinguished 
obstetrician, " the three imperative indica- 
tions ; that of subduing the movements of the 
bladder, of locking tip the bowels, and of 
enabling the patient to maintain for a long 
period the supine position, which would other- 
wise soon become intolerable." With all 
due respect for the discoverer of the anaes- 
thetic action of chloroform, I can not help 
saying, that if there is any thing in the after- 
treatment of the operation in question which 
might be dispensed with, it is surely the 
opium. Amongst the cases reported by me 
there are some where an early evacuation of 
the bowels took place, though opium had 
freely been giveu ; and I have seen others, 
when no opium had been administered, re- 
main constipated during the whole time of 
the confinement in bed. In some cases the 
patient suffered more from the retention of 
the faeces, than either from the operation or 
from being laid up in bed. Having observed 
that many patients were much benefitted by 
an"evacuation of the bowels, I have adopted 
the rule, instead of giving opium, to evacuate 
the bowels by water injections whenever it 
was required, and I have never had reason 
to repent having done so. Besides, theoret- 
ically considered, I am unable to comprehend 



M. Schuppeet on Vesico-Vaginal Fistula. 



13 



what harm could possibly result to the parts 
operated upon by an evacuation of the 
bowels. '"What is the use of experience if 
not guided by reflection I " 

Xo other operation, comparatively speak- 
ing, causes so little reaction on the system 
as the operation for vesico-vaginal fistula. 
During- the time the patient is confined to 
her bed, a light diet should be adhered to. 
Physic will seldom be required. 

One word about the administration of 
chloroform : The oxieration of vesico-vaginal 
fistula is not a very painful one ; I have ope- 
rated on some women who did not feel the 
slightest pain : so far the anaesthetic might 
be dispensed with ; but there is another 
reason why I should always offer its adminis- 
tration, and that reason is best felt by the 
patient. 



B. Cases. 

Case I. — Of the first case operated upon 
by me, in February, 1S58, and published 
in the Mew Orleans Medical Mews and Hos- 
pital Gazette, in March, 1858, I will only 
mention here that success was attained 
by one operation, although the patient 
had been previously operated upon unsuc- 
cessfully by other physicians in this city. 
The fistula was situated near the neck of the 
bladder, five centimetres distant from the 
external mouth of the urethra, measured one 
centimetre in the long axis, which lay in a 
transverse direction. The pared edges of 
the fistulous opening were united anterio- 
posteriorly with five silver wires, employing 
Bozeman's method. All the ligatures were 
passed through the coats of the bladder, 
without causing either a new fistula or any 
other bad symptom. Hardly any pain was 
experienced by the patient, who was operated 
upon, at her recpiest, without the administra- 
tion of chloroform. 



Case II. — Vesico-vaginal fistula with prolap- 
sus of the in rertcd bladder; the fistula situated 
35""" above the orifice of the urethra; largest 
diameter, transverse, measuring 15 m "'; button 
suture. Cure. 

M. H., a native of Ireland, was over 30 
years old, when she, for the first time, became 
pregnant. According to her statement, she 
carried the child to the full term, had been 
in. labor-pain three days, and was delivered 
of a dead child by instruments. Seven days 
after delivery she observed urine coming 
from the vagina. The fistula was of four 
years standing ; no operation having ever 
been attempted, and the patient had never 
menstruated since its appearance. The con- 
figuration of the hairy part of the vulva 
reminded me forcibly of the incrustations 
observed in salt works, the hair being envel- 
oped by urinary deposits. The inner part of 
the thighs were excoriated to a great extent, 
as also the nates, and both were covered by 
a pustulous eruption. Through the rent in 
the vagina the inverted fundus of the blad- 
der protruded extensively, presenting a 
blood-colored tumor of the size of a hen's 
egg, completely closing the entrance of the 
vagina. After the reposition of the bladder 
three fingers could easily be introduced into 
the fistulous opening. The lumen of the 
vagina was shortened to a depth of 55 mm . 
The posterior edge of the fistula was like a 
stretched cord, dividing the vagina into two 
parts. The upper portion contained what 
remained of the neck of the uterus. The 
posterior edge of the fistula was to a consid- 
erable extent dragged into the fistulous open- 
ing. On the 7th of May, 1858, the woman 
was brought under the influence of chloro- 
form. In order to get access to the upper 
edge of the fistula, for the purpose of paring 
it off, it was necessary to make two lateral 
incisions near the corners of the fistulous 
opening, by which the margin was relieved 
from its confinement. Both edges of the 
fistula were then vivified to the extent of on 
centimetre, and united by seven silver wire 



14 



M. Schuppekt on Vesico- Vaginal Fistula. 



sutures ( ' ' button suture "). Almost all of the 
sutures were passed through the mucous 
membrane of the bladder, to obtain a perfect 
co-aptation of the edges. Opium was admin- 
istered to keep the bowels confined ; a cathe- 
ter was adjusted, and the patient placed upon 
a mattress. The catheter was removed twice 
a day and cleaned in diluted nitric acid. 
Cold water injections into the bladder were 
frequently made during the first forty-eight 
hours. On the thirjd day, in trying to remove 
the catheter, a difficulty was experienced, 
some of the mucous membrane of the neck 
of the bladder having become imbedded in 
its openings, which were of 3 mm in diameter. 
This led me to exchange the catheter for one, 
the holes of which were not larger than l mm , 
and since that time I have never experienced 
the same difficulty. The sutures were remo- 
ved on the tenth day ; the fistula was found 
to be perfectly closed. Injecting the bladder 
to its full extent with water, not a drop es- 
caped through the vagina. The patient did 
not long enjoy her happiness. About three 
months later she died from yellow fever, a 
disease in which silver sutures are una- 
vailing. 

Case III. — Vesico-vaginal fistula; 1 centi- 
metre above the neck of the bladder ; its long 
axis transverse, measuring 8 mm ; one operation. 
Cure. 

C. B., an otherwise healthy and stout 
woman, 24 years old, called on me in August, 
1858, to ascertain whether or not she was in 
the family way. She stated that a physician 
had told her to be careful not to get with 
child again, and that she suffered from an 
incurable disease. About three years pre- 
viously she had been confined with her first 
child ; the labor pains had lasted about 
forty-eight hours ; the child had been born 
with the breech presentation ; no instru- 
ments were used, and she had been delivered 
by a midwife. The urine had come from her 
" privates" eight days after her delivery, and 
continued doing so ever since ; she could 
retain her "water" for a considerable time 



when out of bed ; menstruation had not 
ceased. She had suffered an abortion two 
years after her first delivery. Having made 
an exploration, I told her that although I could 
not tell her for a certainty whether or not 
she was in the family way, I felt assured that 
her " incurable disease" could be remedied. 
Consenting to the operation, I ordered an 
evacuation of her bowels, and fixed the next 
day for the operation. Chloroform being 
administered, the woman was laid on her 
knees, her head, chest and abdomen being 
supported by pillows. The lever speculum 
was then introduced, the edges of the fistula 
pared off and united by five silver wire su- 
tures (button suture). Two grains of opium 
having been given, the patient remained con- 
stipated five days, when, complaining much 
of headache, her bowels were relieved by 
injections, after which the headache left her. 
The button with the sutures were removed 
on the tenth day ; the fistvda had disappear- 
ed. I kept her in bed three days longer, 
when the catheter was taken away to be re- 
applied every three hours. On the fourteenth 
day after the operation the woman was dis- 
charged cured. 

It was subsequently proved that she had 
been in the family way at the time of the 
operation. When about seven months preg- 
nant she called on me again. Finding the 
pelvis normal, and the vagina in a proper 
condition, I saw no necessity for inducing 
premature labor. On the 2d of March, 1859, 
I was sent for ; but when I arrived she had 
already given birth to a child, and without a 
reproduction of the fistula. 

Remarks. — This case proves that menstru- 
ation will not always cease with the produc- 
tion of a vesico-vaginal fistula ; and it also 
does not speak in favor of the assertion ad- 
vanced by Braun, in Vienna, that sterility 
was a necessary consequence of such a fistula, 
" because the urine would destroy the sper- 
matozoa," a view which has already been 
refuted by Esmarch, in Kiel, and J. B. Brown, 
in .London. 



M. SCHUPPEBT on Tesico-Yayinal Fistula. 



15 



Case V. — Yesieo-rayinal fistula ; five milli- 
metres above the neck of the bladder ; one ope- 
ration ; Cure. Second operation for stone in 
the bladder, Cotyocystotomia ; new fistula; 
operation : Cure. 

The previous history of this case (remark- 
able in more than one respect) I will copy 
from the Medical Xeics and Hosjntal Gazette, 
of New Orleans, for 1854, vol. 1, p. G2 :— T. D., 
a native of France, has resided in New Or- 
leans for-the past four or five years. On the 
fifteenth of October, after a painful and 
tedious labor, which lasted three days, she 
was deUvered of a dead child. She was at- 
tended during confinement only by an old 
negro woman. The morning succeeding her 
delivery, she perceived that there was a flow 
of urine per vaginam. This induced her to 
enter the Charity Hospital, where she was 
admitted six days (one month, according to 
the patient's statement to me) after her de- 
livery. She only remained three days, and 
having undergone no treatment, she left 
without having derived any beneflt. She 
returned home, where she was visited by 
several physicians, one of whom, after a 
careful examination, pronounced the case one 
of prolapsus uteri, and introduced a pessary, 
which he ordered should remain undisturbed ; 
this came away one month after its introduc- 
tion, when, finding that no relief had been 
obtained, the patient did not re-introduce it. 

She left New Orleans soon after for Mobile, 
where, having consulted a physician for in- 
termittent fever, with which she was at the 
time afflicted, she was correctly and for the 
first time informed of the nature of her 
malady, and told that an operation would be 
necessary to effect a cure. She returned 
soon afterwards to New Orleans, determined 
to enter the Charity Hospital, in which insti- 
tution she was admitted. She was admitted 
on the 10th of October, and was placed under 
the charge of Dr. E. Martin. On the 12th of 
October, the patient having been brought 
into the operating theatre at the hospital, an 
attempt was made to place her properly 



under the influence of chloroform ; but this, 
although but a small quantity was used, was 
found to produce such violent and dangerous 
symptoms of syncope, that its use was sus- 
pended, and it was determined to operate 
without it. The operation was performed in 
the following manner: The patient was 
placed upon her back, on a table provided 
with a mattress, and her legs fixed at right 
angles with her thighs, which were kept sepa- 
rated by two assistants. Upon the introduc- 
tion of three valves of a speculum, two of 
which passed laterally, the third inferiorly, 
the fistula was brought into view. This was 
situated in the centre of an elevation of a 
darker color than the surrounding parts, and 
corresponded to the situation of the trigone 
cervicale of the bladder ; its diameter was 
about two lines and a half. With a straight 
bistoury Dr. Martin made a semi-lunar in- 
cision in the vesico- vaginal septum, which 
commenced at the posterior portion of the 
fistula, immediately below the elevation sur- 
rounding it, and was directed backward in 
such a manner as to form a curve of about 
ninety degrees. This incision was nine lines 
in length by about one line and a half in 
depth ; next, by the aid of a pair of forceps, 
the operator raised up a flap from the vesico- 
vaginal septum, Avhich flap corresponded 
with the incision already described ; this 
part of the operation lasted about twenty 
minutes, the state of the patient being such 
as to require several intervals of repose. 
The second part of the operation consisted in 
forming an anterior flap in the same man- 
ner, and of the same form as the last, with 
the exception that the convex portion, in- 
stead of being directed backwards, was di- 
rected in front. To effect this, the patient 
was placed on the abdomen, the legs extended 
and separated, and the pelvis approached to 
the edge of the table ; this portion of the 
operation was more difficult than the last, on 
account of the extreme weakness of the pa- 
tient, and the extravasation of blood into the 
vagina, caused by the division of a small 



16 



M, ScHUPrERT on Vesico- Vaginal Fistula. 



arterial branch. The second flap being form- 
ed, twenty minutes repose was allowed to the 
patient, wliich time was employed in stopping 
the haemorrhage. This being effected, Dr. 
Martin next proceeded to unite the flaps. To 
do this, the branches of the speculum were 
again introduced, the convex edges of the 
flaps approximated and united by interrupted 
sutures. The operation being terminated, the 
patient was sent back to her bed, and abso- 
lute diet with rest and emolient drinks or- 
dered. A silver catheter was introduced into 
the urethra and permitted to remain for ten 
days, being only removed occasionally for the 
purpose of cleaning it. For the first four 
days succeeding the operation, the patient 
continued to pass a small quantity of urine 
by the fistula ; this soon ceased entirely, and 
the opening remained closed until the first of 
November, when, from an effort caused by 
scrubbing in the ward, the dribbling re-com- 
menced. It became necessary again to freshen 
the borders of the fistula with the scalpel, and 
to re-apply the sutures. Absolute rest was 
then enjoined, and the patient began to im- 
prove again, until the first of February 
(during which time, as the patient stated to 
me, she underwent four other unsuccessful 
operations). When being about to leave the 
hospital, she was imprudent enough to take 
too much exercise (?) which brought on once 
more a slight oozing from the fistula ; this 
was soon checked by the daily application of 
nitrate of silver, and the patient left the 
hospital fiually cured on the 10th of March, 
1854" — to enter my Infirmary in order to 
undergo another operation on that fistula, of 
wliich, as the patient asserted, she had never 
been cured. 

When the patient came under my care, in 
April, 1858, 1 found above the neck of the 
bladder a fistulous track of a tubular form, 
the opening of which permitted the introduc- 
tion of the extremity of the index finger. A 
thick fleshy lobe, the " posterior flap" in Mar- 
tin's operation, was found covering the mouth 
of the fistula. On the 9th of April , chloroform 



was administered to the woman, ?t being 
found that she had a very irritable urethra and 
bladder, so much so that the introduction of 
a catheter brought on spasm. She bore the 
administration of the chloroform remarkably 
well, not showing any symptoms of "syn- 
cope." The patient was placed on her knees, 
her abdomen and chest being supported by 
pillows. That flap, which had cost so much 
labor to get there in the previous operation, 
was entirely cut off, when the fistulous open- 
ing lea-ding to the bladder came into full 
view. After its borders had been freely denu- 
ded, it was closed by five silver wire sutures, 
fastened according to Bozeman's plan. All 
the wires were passed through the bladder. 
When the effect of the chloroform began to 
abate, the patient vomited a great deal, and 
this vomiting continued during almost all of 
the two subsequent days. A catheter was 
applied as usual, and two grains of opium 
given. The patient complained during the 
following four days of a great tenderness 
in the hypogastric region. She remained 
constipated for nine days, when the sutures 
were removed. Two of the sutures, after 
being clipped off between the shot and the 
plate, were, after removing the plate, found 
so deeply imbedded in the tissues of the 
vagina that they could not be found at that 
time. One of them was extracted about 
three weeks afterwards ; the other remained 
undiscovered (vide following operation). A 
complete cure was the result of this opera- 
tion. The joy of the poor woman, after four 
years of suffering, being besides previously 
told by several physicians that her case was 
a hopeless one, in seeing herself freed from a 
loathsome disease, is beyond description. 

Operation for Stone in the Bladder on the 
same woman. — In November, 1860, being 
called upon, I found her suffering a great 
deal from a " pain in her bladder." Upon an 
examination, a large stone was discovered. 
I invited her to my Infirmary, where she was 
operated upon on the 30th of November. 
Being entirely under the influence of chloro- 
form, she was placed on the operating table 



M. ScittrrPEfeT on Vesico-Vaginal Fistula. 



17 



in the position for lithotomy. The vagina 
was dilated by two broad, blunted books. A 
stone-sound, grooved on the outside of the 
curve, was introduced into the bladder, and 
pushed toward the anterior wall of the vagina, 
against a gorgeret, whieb was held in contact 
with that place in the vagina. In searching 
for the end of the sound, my ringer discovered 
a pieeeof a metallic thread, which, when ex- 
tracted, proved to be that portion of the 
wire suture which could not be found in the 
former operation, and which had remained in 
the tissues for over two years and a half 
without having caused a fistulous opening. 
The point of the bistoury, now inserted thirty 
millimetres from the mouth of the urethra. 
was thrust through the integuments till it 
was imbedded in the groove of the director ; 
thence it was pushed in the direction of the 
uterus. The cut measured 45 mm in length. 
The stone was then removed with the forceps. 
A severe haemorrhage took place. The pa- 
tient suffered again for two days with violent 
vomiting, from the affects of the chloroiorin. 
Xo bad symptoms followed the operation. 
The stone, of the shape of a testicle (singu- 
lar, is it not ?) cut in two equal halves, mea- 
sured on the cut surface 30 by 50"""; its 
weight was one ounce and 30 grains, and it 
consisted of mixed phosphates. 

Operation for dosing Fistula. — The wound 
was left to itself, in order to observe what 
nature woidd accomplish. On the 19th of 
December, twenty days after the last opera- 
tion, the wound had narrowed to 20""" in 
length ; but there was very little prospect 
that nature would accomplish more without 
assistance. I vivified the borders of the open- 
ing, closing it by six silver sutures and a 
button, in the long axis of the vagina. The 
edges of the wound were united before bleed- 
ing had ceased. The needle was thrust 
through the whole thickness of the bladder, 
the lowest stitch comprising, undoubtedly', a 
portion of the urethra. The patient walked 
up stairs after the operation and went to bed, 
where she adjusted the catheter herself, 



having attained sufficient experience in han- 
dling it. No chloroform had this time been 
administered, and no vomiting was experi- 
enced. Eleven days after the operation, the 
sutures were removed ; but, after chipping off 
the shot over the silver plate, and raising the 
latter, the suture which comprised the ure- 
thra was found so imbedded in the tissues 
that it was left behind. About six days later 
this piece of silver wire was extracted ; but it ■ 
left an opening through which urine escaped 
occasionally by drops. I cauterized this 
stitch-bole for several weeks with nitrate of 
silver, but without any good effect. I then 
cut out a portion of the surrounding tissue, 
and applied one silver wire suture, fastened 
over a small button of lead. When the but- 
ton and suture were removed, I was not a 
little annoyed to meet with another failure, 
though the stitch-hole was so small that, only 
at long intervals and when the bladder was 
distended with urine, the latter would escape. 
I sent the woman home, advising her to touch 
the fistulous opening occasionally with the 
nitrate of silver. A month subsequently, on 
calling to see her, I was informed that she 
had gone to the country, and that is the last 
I have heard from her. Has the opening 
closed 1 I doubt the affirmative, from the 
experience I have had with the use of nitrate 
of silver, which seems to favor only French 
surgeons. 

Remarks. — On discovering the stone, the 
first idea which struck me in reference to its 
origin was, that the piece of silver wire 
suture, which had been lost in my former 
operation, might possibly have found its way 
into the bladder, and there given rise to the 
formation of stone. But when the woman 
was placed in position for lithotomy, I found 
that piece of wire, it having by that time 
worked its way partially out of the tissues ; 
and though extracted at so late a date, it did 
not leave behind it a fistulous opening. On 
questioning the patient closely, her state- 
ment was, that nearly six months before her 
delivery, 'she had already suffered a good 



18 



M. ScnurrERT on Vesico- Vaginal Fistula. 



deal from her bladder; and the symptoms 
she described left no doubt in my mind that 
she had at that time already been afflicted 
with stone. It is nevertheless strange that 
in the many operations she underwent, and 
the numerous times the catheter was applied, 
the stone should have escaped detection. I 
also recollect, that all the symptoms the 
patient complained of in November, 1860, 
-were present when I examined her for the 
first time, in April, 1858 ; but I attributed 
them at that time to an irritability of the 
bladder. Stone is mentioned among the 
causes of vesico- vaginal fistula in parturition, 
though I never but once heard of such a 
case. Although of rare occurrence, it will 
certainly do no harm, and it may be produc- 
tive of good, to examine the bladder tho- 
roughly before an operation for vesico- vagi- 
nal fistula is undertaken. Had I done so, I 
would have saved the poor woman much 
suffering and spared myself two subsequent 
operations. In reference to the cause of the 
fistulous track, left after the extraction of the 
silver wire, "which had passed through the 
walls of the urethral canal, I will not venture 
an explanation. Though the needle had 
entered both walls to an equal depth, there 
was only one fistulous opening resulting. 

Case VI. — Vesico-vaginal Fistula, 25 mm above 
the external orifice of the urethra ; size of a 
small bean; button suture. Death from puru- 
lent infection. 

E. B., a native of Scotland, twenty-four 
years of age, of a delicate and irritable con- 
stitution, who had recently been delivered in 
this city, was operated upon by me at the 
Infirmary, on the 7th of June, 1859. Chlo- 
roform was administered, the effect of which 
lasted over three hours, during which the 
patient was literally bathed in perspiration, 
but felt well when coming out from under 
the influence of the anaesthetic. The edges 
of the small fistula, when pared off, bled 
profusely, rendering the use of ice necessary 
for several hours, in order to arrest the 



haemorrhage. The fistula was closed by three 
silver wire sutures, inserted by Bozeman's 
method. The patient being very delicate, I 
but naturally treated her with all the con- 
sideration that the circumstances admitted, 
doing or omitting nothing which might in- 
terfere with the success of the operation ; 
and in this connection may be mentioned, 
that particular care was taken, in this case, 
to apply the sutures in such a manner as to 
avoid wounding the mucous coat of the blad- 
der. On the night of the 10th, menstruation 
took place and became profuse ; during the 
next day fever set in, the pulse rising to 110 
and beating but feebly, while the skin was 
hot and dry. On the 12th, the catamenial 
discharge was still profuse, accompanied by 
great thirst and restlessness. 13th, pulse 
160, cheeks reddened, profuse perspiration, 
and vomiting of bilious matter. 14th, pulse 
threadlike, eyes glassy, tongue clear and red ; 
delirium and subsultus tendinum. On the 
15th, the patient died. A post mortem ex- 
amination was not permitted by her friends. 

Remarks. — This was a case in which all the 
circumstances were apparently favorable for 
a speedy cure. The fistula was small, and 
there was an extensive field to operate upon. 
I am positive, that in this case the bladder 
was not touched, either by knife or needle, 
though I do not lay much stress upon this 
fact, having learned to consider needle 
wounds of that organ as of not much import- 
ance. Dr. J. Baker Brown, of London, has 
reported a similar case, where death resulted 
from pyaemia, after the operation, in a newly 
delivered woman, with milk still in her breast. 
That circumstance may deserve attention. 

Case VII. — Vesico-vaginal Fistula at the 
trigonnm vesicale ; transverse diameter 40 mm ; 
longitudinal 15 mm ; prolapsus of the inverted 
bladder; one operation. Cure. 

A. K., twenty-six years old, a native of 
Belaud, living at Algiers, parish of Orleans, 
was taken with labor pains on the 7th of De- 
cember, 1857, at 10 o'clock, p. m., and deliv- 



M. ScnurrERT on Vesico-Vaginal Fistula. 



19 



ered instrtunentally of a dead child on the 
9th, at 5 r. ar. During her delivery, she 
stared that she felt such acute pain in her 
left ankle, that she thought the doctor had 
fractured it. For ten weeks after her deliv- 
ery she could not walk, and since then has 
constantly complained of pain in that part ; 
it being- more painful in rainy weather than 
at other times. She further stated that at 
times her foot became so cold as to render 
artificial heat necessary. In July, 185S, she 
went to a private hospital in this city, where 
she was operated upon. She remained at the 
hospital one month, but came home without 
feeing benefitted. On the 10th of May, 1S59, 
she entered my Infirmary, being much re- 
duced in health, and so feeble that she could 
hardly " keep on her feet." On the 18th of 
May, she was brought under the influence of 
chloroform. The callous and expanded edges 
of the fistula rendered it necessary to make 
lateral incisions. Much bleeding took place, 
which retarded the progress of the operation 
considerably. The edges, released by the 
lateral incisions, were pared off and united 
by seven silver sutures and a button. Iu 
order to secure a firm union of the edges, and 
collect more facts, in order to prove beyond 
doubt the innoxiousness of the metallic su- 
tures, all of the sutures were passed through 
the whole thickness of the bladder. Two 
grains of opium were given. The patient did 
not sleep during the night, and had an evac- 
uation the next day. On the 20th, five days 
after the operation, an injection of water into 
the bladder, followed by a leaking from under 
the button, proved that perfect union had 
not yet taken place. Four days later, when 
the injection was repeated, no water escaped 
by the vagina. The sutures were removed 
on the twelfth day, the fistula being cured. 
Three days later, the patient was allowed to 
leave her bed. 

On the 7 th of June, she observed urine 
coming from the vagina. An examination 
revealed a small fistulous opening situated 
in one of the lateral incisions, which undoubt- 



edly had been made too deep. This fistula 
was closed by two interrupted sutures, after 
the surrounding membrane had been erased 
by the rugine. The woman was discharged 
from the Infirmary perfectly cured, and about 
nine months later, when I saw her again, she 
had so much changed in appearance that I 
did not recognize her features until she told 
me who she was. 

Bcmarls. — This patient, since her delivery, 
had not menstruated for over a year, though 
three days in every mozith she complained of 
great pain in the hypogastric region. She is 
now, four years after the operation, perfectly 
regular iu her menstruation. She has not 
conceived again. In curing this fistula, the 
lateral incisions were undoubtedly of much 
value, but care is necessary to avoid cutting 
too deep. Notwithstanding the penetration 
of the bladder by the needle fourteen times, 
no new fistula or any other bad result fol- 
lowed. The leaking of the fistula on the fifth 
day cautions us not to remove the sutures too 
early. Opium did not check the bowels, and 
no bad effect followed their evacuation. 

Case VIII. — Vesico-vaginal Fistula, including 
the necli of the bladder; transverse diameter 
50 mm ; longitudinal diameter 20 mm ; prolapsus of 
the inverted bladder; loss of perineum ; twelve 
silver icire sutures applied in three separate 
operations ; each operation successful. 

N. D., a native of Tipperary, Ireland, age 
unknown, said that she came from a country 
where it was not customary to keep the 
record of a woman's age. She was married 
in July, 1856, at Algiers, parish of Orleans, 
La ; became pregnant, but miscarried four 
months afterwards. Two months later was 
again gravid, and this time carried the foetus 
to full term. The labor pains began on the 
16th of December, 1857, at 3 o'clock, A. m., 
and she was delivered with the forceps on 
the 19th, at 2 o'clock, A. m. During, the two 
days immediately succeeding delivery, she 
did not urinate, when " the water came away 
all at once," and in such a quantity that her 



20 



M. Soiiuppeet on Vesico-Vaginal Fistula, 



bed " became overflowed." She thought that 
her bladder had burst. She further stated, 
that sometimes, for a day or two, the urine 
came only by drops, and that at such times 
she felt a burning pain, as if caused by a hot 
iron, and that the pain left her as soon as the 
urine began to flow freely. For twelve 
months after her delivery she could neither 
stand nor walk. She further stated, that as 
soon as she became able to walk, she went to 
a " doctor," who told her that she was suffer- 
ing from a falling of the womb (mistaking 
probably the prolapsing bladder for the 
uterus), and that the doctor had given her 
some medicine for it. She received no better 
treatment at the hands of another JEseula- 
pius, who promised her to bring back her 
" courses," saying that after this she would 
be entirely relieved. After her friend (men- 
tioned in Case YII) had been cured, she ap- 
plied to me to " put her through the opera- 
tion." The preceding case had made on my 
mind a deep impression, but the condition of 
this unhappy woman impressed on me still 
more forcibly the amount of suffering and 
pain that human flesh is heir to. The pro- 
truding arid everted bladder, in a high state 
of hyperemia, bleeding at the least touch, 
covered the entrance of the vagina, resem- 
bling an orange in shape and size. The 
perineum was gone. The labia majora, nates 
and inner side of the thighs were excoriated, 
the pudendal hair being incrustated with 
urinary deposits. A more pitiable picture 
than this woman presented, could hardly be 
imagined. After the bladder was pushed 
back, four fingers could be inserted into the 
iistulous opening. No traces of the uterus 
coidd be found, the vagina ending in a eul de 
sac, having a small opening in one corner, 
which probably communicated with the ute- 
rus. The rent in the vagina stood wide open , 
its edges being callous, and on the right side 
closely attached to the ramus ischii. Ad- 
hering still to the use of the button suture, 
I resolved to try to accomplish the oblitera- 
tion of the greater portion of the fistula, 



leaving the closing of the two corners for 
subsequent operations. 

On the 23d of August, 1859, the patient 
was brought under the influence of chloro- 
form ; and after having made, as in the pre- 
ceding case, two lateral incisions, the edges 
were properly pared off and united by seven 
sutures, fastened over a silver button. 
All of the sutures Avere carried through the 
whole thickness of the bladder. A profuse 
bleeding Avhich took place, Avas arrested by 
tying the sutures. ISTo accident worth men- 
tioning happened. Eight days afterwards, 
on the 13th of August, the plate and sutures 
were removed, and the fistula, as far as 
brought under treatment, Avas found to be 
perfectly closed, presenting a linear cicatrix. 
The patient aa^is retained in bed with the 
catheter in the bladder for five subsequent 
days, and during that time no urine escaped 
through the remaining portions of the fistula. 

On the 9th of September, the speculum 
Avas introduced into the vagina, and water 
injected by the urethra, when it Avas observed 
to come out on both ends of the united edges 
of the fistula. The edges of the opening to 
the right were now pared off with the rttgine, 
being found to be very thin, adhering to the 
ramus ischii closely, and being immovable ; 
they were detached from the bone by sub- 
cutaneous dissection, after which they were 
united by three interrupted twisted sutures. 
On the following day the patient complained 
of pain in the abdomen, and Avas troubled 
with suppression of urine, lasting from 4 p. 
M. till 10 o'clock next morning. During tins 
time no urine passed through the catheter ; 
of this complaint the patient had suffered 
occasionally ever since her delivery. Though 
no opium had been given her, she remained 
constipated over nine days, when the bowels 
were evacuated by water injections into the 
rectum. 

The sutures Avere remoA r ed on the 16th: 
The fistulous opening being closed, the pa- 
tient was allowed to leaAe her bed. On the 
night of the 18th, there was a renewed attack 






M. SCHUPPERT on Vesico-Vaqinal Fistula. 



21 



of suppression of urine, accompanied with 
the same pain in her abdomen. On the 28th, 

she was ordered to bed again, to have the 
remaining opening operated upon. This 
opening was of the size of a small bean, and 
was closed by two interrupted sutures. At 
night the catheter became obstructed, and 
urine collected in the bladder, causing the 
patient great uneasiness. At 5 o'clock in 
the morning I was called by the nurse. In 
removing the catheter and introducing ano- 
ther one. a great quantity of urine came 
away, a proof that the opening into the 
vagina was properly secured. Seven days 
later the sutures were removed, and I ob- 
served to my satisfaction, and not less to that 
of the sufferer, that the cure was complete. 

One year later, I was informed by Dr. 
Hassenburg, who was practising at that time 
at Algiers, La., that he had removed from 
the urethra several stones (gravel). This 
fact explains the suppression of mine from 
which the patient suffered so much at differ- 
ent periods, when the stones were passing 
through the ureter. 

Remarks. — This case again proves the value 
of lateral incisions, without which the edges 
of the wounds could not have been brought 
in proper co-aptation. The subcutaneous 
dissection of parts of the fistulous borders 
from their close attachment to the bone, 
greatly contributed to the final success of 
the operation ; and the results, following the 
penetration of the bladder by the needle and 
wire, do not corroborate the apprehensions 
of those who still consider the bladder as a 
" noli me tangerc." The obliteration of the 
fistula might probably have been accomplish- 
ed at one operation, by the exclusive use of 
the interrupted sutiu'e. No opium was given, 
yet the bowels remained constipated, until 
relieved on the ninth day. 

Case IX. — Vesicovaginal Fistula near the 
icelc of the bladder; transverse diameter 8" ,m ; 
'me operation. Cure. 

Kitty, a stout negro woman, between 



twenty and twenty-live years of age, slave 
of M. L. M., of Natchez, Miss., was brought 
under my professional care in the early part 
of December, 1850. She had been delivered 
of her first child three years previous to that 
time, after having been in labor four days. 
She had been attended by an old colored 
woman, who delivered her of a dead child. 
Three days after delivery a fistula became 
established ; and although the urine con- 
stantly came away from her through the fis- 
tula, she became pregnant again and bore a 
second child in August, 1859 (vide Case III) ; 
this child Avas born alive. The patient was 
operated upon Dec. 15th ; all of the sutures 
were passed through the walls of the bladder. 
The bleeding which ensued from vivifying 
the borders was unusually profuse, and not 
being arrested by the application of ice and 
compression, the edges w T ere united, The. 
bleeding continued in a small degree during 
several hours, causing me to doubt whether 
the sutures were sufficiently tightened. No 
chloroform had been administered, and the 
patient did not complain of pain from the 
operation. The patient left the operating 
table and walked up stairs to her room. 
After the application of the catheter, no 
urine whatever escaped but through the 
catheter. 

On the sixth day after the operation, I 
introduced the speculum and injected water 
into the bladder, when a slight leakage en- 
sued from under the button. The patient 
was kept in bed six days longer, when the 
injection being repeated, and no fluid escap- 
ing from the former place, the sutures were 
removed. She was discharged from the In- 
firmary fourteen days later, perfectly cured. 

Remarks. — This case again cautions us 
against removing the sutures too early. Six 
days after the operation no complete union 
had taken place. The history of this ease 
does also not speak in favor of the opinion, 
that sterility w^as a necessary consequence 
of such a fistula, " because the urine would 
destroy the spermatozoa." (Vide Case III.) 



22 



M. Schuppeet on Vesico- Vaginal Fistula. 



Case X. — Urethro-vesieo-vaginal Fistula of 
an enormous extent ; partial obliteration of tlie 
urethra ; one operation. Death from pulmo- 
nary consumption. 

Betsy, colored, sixteen years old, a slave 
of 0. M., of this city, was admitted to the 
Infirmary in February, 1800. She had been 
confined two years previously, when living 
in the country. The labor pain had lasted 
seven days, and she had been delivered by a 
doctor, who attended her during the last 
three days of her confinement. According 
to the patient's statement, no instruments 
were used, and the fistula occurred before 
delivery was accomplished. Upon examina- 
tion, the whole vesico-vaginal septum, inclu- 
ding the neck of the bladder, was found de- 
stroyed ; of the urethral canal, only l cm was 
left. Through this wide chasm the remain- 
ing portion of the bladder protruded. The 
inner end of the urethra was obliterated and 
closely adherent to the os pubis. The labia 
majora were thickly covered with condylo- 
mas ; the pudendal hair incrustated with 
urinary deposits ; the nates and inner parts 
of thighs denuded of epithelium and covered 
with ulcers; the inverted and protruding 
bladder, in a high state of hyperemia ; the 
action of both ureters, ejaculating the mine 
in small streams to a considerable distance, 
occasionally as far as 18™, and at intervals of 
from ten to twelve seconds, was a phenome- 
non of great interest to all present. The 
vagina ended in a cul de sac, communicating 
through a narrow opening with the uterus, 
and by which the menstrual blood came away 
at the regular periods. Though a desperate 
case, yet, encouraged by the success I had so 
far met with in former operations, I did not 
despair of being able to overcome all the 
obstacles here presented. The first step ren- 
dered necessary, was to obtain a permeable 
urethra. In order to effect this, a trocar was 
introduced in the orifice of the urethra and 
the obliterated portion of it perforated. A 
catheter was then permanently lodged in the 
canal. A large silver cylinder, constructed 



for the purpose, was then introduced through 
the fistulous opening, to retain the bladder 
in its normal place. This cylinder was made 
to fit the opening of the fistula accurately, 
so that no urine escaped but through the 
catheter. The consequence of this was, that 
all the sores began to heal rapidly, further 
contact with the urine being prevented. 
Four weeks later, when the cylinder was 
removed, the bladder remained in its place. 

On the 15th of March, the patient was ope- 
rated upon. The lower portion of the vagina 
was extensively detached from the os pubis, 
in order to gain sufficient movable material, 
to bring the edges in co-aptation. After 
having pared the borders, the wound was 
closed, Avithout difficulty, by eight silver su- 
tures and a button. The bleeding was con- 
siderable. 

Twelve days afterwards, on removing the 
sutures, the fistula was found closed, with 
the exception of a small opening of the size 
of a five cent piece, to the left of the urethra, 
where the thin tissues had sloughed away. 
Three days after the operation, the patient 
began to suffer nightly fevers, with profuse 
perspiration, accompanied by a severe cough, 
and soon copious expectoration took place. 
In the course of time, vomicas became estab- 
lished in both lungs. All medication proved 
nugatory, and the patient became reduced 
lower and lower, till only a skeleton remained. 
She expired on the 15th of December, nine 
months after the operation. 

Remarks. — Here we have a large fistula 
accompanied by a regular catamenial dis- 
charge, the co-existence of which is denied 
by some writers on the subject. The action 
of both ureters was in full view, a phenome- 
non most assuredly seldom witnessed. The 
distance to which the urine was expelled by 
the ureters, may give an idea of the powerful 
action of their muscles, and in their peri- 
staltic contraction the main force is undoubt- 
edly to be found, by Avhich stones formed in 
the kidney are driven through the small 
lumen of the ureter ; this also gives us the 



M. SCHUPPERT aw Vesico-Vaginul Fistula. 



key to the excruciating' pain experienced by 
those who sutt'er from such a disease. The 
alternate contraction of the ureters further 
prove, that the excitation of their respective 
serves must originate in distinct and sepa- 
rate localities. The death of the patient, 
though protracted during nine months, I 
have no hesitation to attribute to the opera- 
tion : an embolic process localized in the 
lungs, ending in their slow*but utter destruc- 
tion. 

Case XL — Urethro-vesieo-vagined Fistula ; 
transverse diameter 15 mm ; longitudinal 30 mm ; 
partial obliteration of the urethra ; tieo opera- 
tions. Cure. 

Rosalia, mulatto woman, about thirty years 
old, slave of L. D., of Pointe Coupee, La., 
was admitted into the Infirmary in August, 
1860. She had previously given birth to two 
children. At the third parturition, her labor 
pains lasted four days, during which time 
she was attended by a colored woman. The 
urine passed through the vagina on the third 
day after delivery. The lower margin of the 
fistula was at a distance of nearly 20 mm from 
the external orifice of the methra. Intro- 
ducing a catheter into the urethra, the latter 
was found to be permeable 14 mm in length, 
when it became obliterated, and closely ad- 
hering to the os pubis. By the most careful 
and precise scrutiny on the part of all the 
medical gentlemen present, no traces of the 
uterus or of any orifice leading to it could be 
found. The vagina ended in a cul de sac. 

On the 31st of August, 1860, the patient 
was placed on the operating table, and chlo- 
roform administered. The obliterated por- 
tion of the urethra was first opened with a 
trocar, after which a catheter was adjusted. 
In paring the edges of the fistula, a part of 
its lower margin, which was adhering to the 
os pubis, had to be detached from the bone, 
to make it movable, and to bring it in con- 
tact with the opposite edge, in an anterio- 
posterior position. To accomplish this, a 
lateral incision was also necessary. As the 
thin tissues covering the inner end of the 
urethral canal coidd not afford much loss of 



substance, they were only superficially scari- 
fied and covered by bringing down the upper 
border, so that the artificial opening, made 
in the urethra, became located inside the 
bladder. The edges of the wound were then, 
in that position, closed by six silver sutures 
and a button. Twelve clays later, the su- 
tures were removed. The fistida was found 
to be obliterated, with the exception of a 
small opening to the left of the urethra. 
This was operated upon two days later, and 
permanently closed with two interrupted 
silver sutures. The patient remained at the 
Infirmary until the 3d of November, when 
she was discharged cured. After a lapse of 
five months, she returned, complaining of a 
leaking from the vagina. Upon an examina- 
tion, a small opening was detected, where 
the lateral incision had been made. On April 
11th, an oval piece was excised, having the 
fistulous opening in its centre, and the wound 
was then closed by two interrupted sutures. 
Eight days later, when the sutures were re- 
moved, the fistula had disappeared, and the 
patient Avas sent home one month afterwards, 
permanently cured. 

Remarks. — Although the largest diameter 
of the fistula was situated in the long axis of 
the vagina, stdl the complication which the 
case presented in the obliteration of the ure- 
thra, made it imperative on me to unite the 
edges in an anterio-posterior position. The 
complication mentioned required the greatest 
exactness, and also a delicate handling of 
the thin tissues covering the urethra, in 
order to bring them in proper apposition 
with the posterior margin of the fistula, so 
that the artificial opening made in the ure- 
thra became located inside the bladder. I 
appreciate the success more highly, as the 
operation, though otherwise successful , would, 
without this point being secured, have been 
of little benefit to the patieut. 

Case XII. — Vesico-vagincd Fistula near the 
neclc of the uterus, measuring in its long axis 
15 mm , Cure effected by the third operation. 

Mathilda, slave of F. D. C, of Holmesville, 



2-1 



M. SciiUPPKitx on Vesico-Vaginal Fistula. 



La., was admitted to the Infirmary in De- 
cember, 1860. She was between thirty and 
thirty-five years old, and bad given birth to 
ten children., all horn at the full term. About 
one year previous to her admission, she was 
delivered, after having been in labor pains 
four days. No instruments Avere used. After 
the birth of the child, which was born in 
head presentation, the patient suffered a 
great deal from pain in her lower extremities 
as well as her back, so much so, that she 
could uot bear to be touched. Her legs and 
feet were swollen, and remained in that con- 
dition about four weeks. She had not been 
able to walk for two months, immediately 
preceding my knowledge of the case. Soon 
after her delivery, she felt the urine coming 
from her "the Avrong way." 

She was operated upon on the 17th Decem- 
ber. The greater part of the fistula was situ- 
ated to the right of the neck of the uterus and 
about four millimetres distant from it. The 
longest diameter of the fistula lay in an oblique 
and downward direction. An immovable 
portion of the mucous membrane of the blad- 
der, protruding through the fistula, had to 
be removed by the knife, before the borders 
of the fistula could be properly pared. The 
opening was closed in a longitudinal direc- 
tion, by five silver sutures, adjusted over a 
button. Considerable bleeding occurred from 
vivifying the borders, which was arrested by 
tying the sutures. The patient had some fever 
in the evening, which disappeared the next 
morning. No chloroform had been adminis- 
tered. On the sixth and eleventh days after 
the operation, water was injected into the 
bladder, but each time was observed to come 
out from under the button. Thinking it of 
no use to keep the patient any longer con- 
fined to her bed, the sutures were removed. 
Although the greater part of the fistula was 
closed, it still showed an opening of the size 
of a pea. Another operation was performed 
on the 16th of January. This time the edges 
of the wound were united in a transverse 
direction, by two sutures and the button. 



Five days later the catamenial discharge ap- 
peared. On the tenth day after the operation 
the sutures were removed, but the fistula 
was not obliterated. The patient was then 
sent home, with directions to return in a cou- 
ple of months. Ee-admitted to the Infir- 
mary, she was operated upon on the 12th day 
of April. The fistula had not diminished in 
size. Attributing the want of success, in the 
first two operations to the insufficient denu- 
dation of the edges, or in other words to a 
carelessness, which we are too apt to lapse 
into under certain circumstances, the edges 
were this time pared off to a greater extent 
and united by three interrupted silver sutures, 
two of which were carried through the blad- 
der and a portion of the neck of the uterus. 
Ten days later the sutures were removed, the 
fistula was perfectly closed, and when dis- 
charged on the 27th of May, the patient Avas 
considered perfectly cured. 

Case XIV. — Uretliro-recto-vesico-vaginal Fis- 
tula, with total destruction of urethra; both 
fistulas successfully operated upon, loitli re-estab- 
lishment of an urethra. 

In the winter of 1862, when I was visiting 
Surgeon of the Charity Hospital in this city, 
my attention was called by the nurse of the 
lying-in ward to an unfortunate inmate, Avho 
had for six years walked the rooms of that 
institution, in a most Avretched condition. 
Unsuccessfully operated upon several times 
by different surgeons, she had been given up 
as incurable. Her history Avas the same as 
in most of these cases Avhich happen amongst 
the poorer classes, Adz : protracted labor, 
Avithout proper and timely assistance. She 
had been in labor with her first child over 
four days ; in her delivery no instruments 
were used, and the fistula had become estab- 
lished soon afterwards. When her clothes, 
saturated Avith urine, Avere lifted up, the 
picture Avhich presented itself was indeed 
heart-rending. The thighs, nates, and labia 
majora were excoriated and covered Avith a 
pustulous eruption; the entrance of the 



M. SCHTJPPERT on Vesico-Vaghial Fistula. 



25 



vagina closed by the inverted bladder, with 
its mucous membrane In a high state of 
hyperannia. The bladder was incarcerated 
in the fistulous opening- ; after its reduction, 
which caused considerable pain to the pa- 
tient, the lever speculum was applied, but 
here a still more desperate condition was 
found to exist. With a chasm in the vesico- 
vaginal septum, measuring in its transverse 
diameter 40""", its lower borders immovable, 
adhering to the os pubis, the vagina was 
much shortened, and communicated by 
another fistula with the rectum ; the whole 
urethral canal was gone, only traces of it 
remaining : and yet I was expected to give 
relief, because the patient had been told, that 
I had cured a friend of hers, who had not 
failed to describe her own case as even worse 
than this one. An occlusion of the vagina could 
not be thought of, on account of the absence of 
an urethra, and this very circumstance did not 
give encouragement for a trial of obliteration 
of the fistula, by our method. In such a di- 
lemma, I ordered the patient to bed, in order 
to attend first to the excoriation of the ex- 
ternal parts, and to gain time to decide what 
further steps could be taken in this extremity. 
I placed a large cylinder, perforated with 
many holes, in the bladder, to retain it in a 
normal position, and at the same time to pro- 
vide a proper channel for the passage of the 
urine, to prevent it from coming in conta ct with 
the excoriated parts. While the sores were 
healing, I came to the conclusion to try first 
the obliteration of the fistula, and if success- 
ful, to build up out of the ruins another 
urethra. 

On the Sth of December, I administered 
chloroform.to the patient, and pared off the 
edges of the fistula ; but to obtain an approx- 
imation of the vivified borders, it was neces- 
sary to dissect the adhesion of the lower 
margin of the fistula from the os pubis, 
besides making a lateral incision to the right 
of the fistulous opening. After this had 
been done, the edges could be brought in con- 
tact without any tension of the parts. By 
i 



the application of nine interupted silver 
wire sutures, the fistulous opening was 
closed, notwithstanding the disrespectful ac- 
tion of her rectum, in opening a "battery" 
from the rectal fistula, by which my instru- 
ments as well as the parts operated upon 
were kept continually under fire. In the cen- 
tre of the united borders I had left a small 
opening through which a catheter of two 
millimetres diameter was introduced and re- 
tained. A large dose of opium was given 
to keep the bowels confined, During the 
rest of the day and subsequent night the 
patient suffered much from vomiting, causing 
a bearing down of the boAvels, which made 
me fear for the safety of the operation ; but 
the nausea passed off without doing any 
injury. No urine escaped except through 
the catheter. The bladder was frequently 
injected with cold water daring the several 
subsequent da;, s. 

On the fourth day after the operation, the 
patient discharged from her bowels hard faecal 
matter, accompanied with such a bearing- 
down of the bowels, that the catheter was 
ejected from the bladder. Still no injury to the 
sutures happened. A dose of oleum ricini was 
then given . Fourteen days after the operation 
six of the sutures were removed, the rest of 
them in the third week. InTo cutting out of 
the wire or establishment of a new fistulous 
opening had taken place, although almost all 
of the sutures were carried through the whole 
thickness of the bladder. The fistula was per- 
fectly obliterated. In removing the catheter, 
the opening leading into the bladder was 
filled tip by a small reddish-looking tumor — 
a portion of the mucous membrane of that 
organ, which acted like a stopper. The 
patient, when in a sitting posture, could hold 
her urine for twenty minutes, and in a re- 
cumbent position, several hours. 

On the 26th of January, the recto-vaginal 
fistula was closed by six twisted silver su- 
tures, which, when removed six days later, 
had also effected a cure. Having so far been 
successful, I contemplated the re-establish- 



26 



M. Schuppert on Vesico-Vaginal Fistula. 



inent of an urethra, and in order to have the 
patient more fully under my personal control, 
I removed her to my residence. The remains 
of the former urethra had formed two thick 
ridges, measuring nearly one centimetre in 
length. These ridges I pared off, and then 
made a lateral incision on each side, to gain 
more mobility. A union was then obtained 
by bringing them together over a small cathe- 
ter, of very thin silver plate. The silver wire 
used was likewise of a very small calibre. 
The upper end of this so constituted tube 
was then properly vivified, as also the orifice 
leading to the bladder, and both united by 
interrupted silver sutures. This operation 
was performed to the satisfaction of the 
medical men present, and the result surpass- 
ed my own expectation. After the removal 
of the sutures, on the third day, the new 
canal was established in its entire length. 
At the point where the urethral canal had 
been attached to the orifice leading into the 
bladder, a small opening remained, the wire 
having cut through the thin membrane. 
Using nitrate of silver to narrow the opening, 
it became larger instead of smaller. I there- 
fore desisted from further meddling with it, 
intending at some other time to attempt to 
close it. What was my surprise when, a 
couple of weeks afterwards, on being called 
to her room, I found the whole urethral canal 
gone, and over this a rent in the vagina, in 
which a portion of the bladder was incarce- 
rated, and so painful to the touch, that I had 
to give chloroform to the patient, in order to 
reduce it. 

The thing was a mystery to me. How 
could it have happened 1 A fortnight after- 
ward I operated again to close the fistula ; 
and though I succeeded, success was accom- 
plished but with the relinquishment of the 
hope of ever being able to re-establish ano- 
ther urethra. 

About three weeks afterwards I was again 
called to her bedside, to find a new edition of 
the fistula so lately cured, and another incar- 
ceration of the bladder. This time I Avas re- 



solved to get at the bottom of the mischief. 
I told her that I would not relieve her, unless 
she made a confession how it had happened. 
My suspicion, which had lately been aroused 
that an intimacy existed between her and my 
groom, Avas proved to be correct, and the 
cause of the several injuries thereby revealed. 
The amiable couple went off together and 
ha\ 7 e since been joined in wedlock, and I Avish 
them both the happiness few, I suppose, 
would like to participate in ; yet de gystipus 
non est disputandum. 

Case XV. — Vcsico-vaginal Fistula; trans- 
verse diameter 20"™; longitudinal 35 mm ; one 
operation ; cure. Absence of vaginal portion 
of uterus ; subsequent menstruation th rough th e 
urethra. 

B. D., a native of Ireland, aged twenty-six, 
had been married three years, when, in Sep- 
tember, 1861, she was confined for the first 
time. Having been five days in labor, she 
was delivered by instruments of a dead 
foetus. Five days after delivery she observed 
urine coming from the vagina. When exam- 
ined, no traces of a uterus could be found, 
the A T agina ending in a cul de sac. 

On the 23d of June, 1862, the patient was 
operated upon. The edges vivified were 
united by seA r en silver wire sutures — anterio- 
posteriorly. At the request of my friend, 
Dr. Sternburg, IT. S. A., who Avas desirous to 
see the mode of application of Bozeman's 
button-suture, the latter method was used. 

Two days after the operation, patient 
complained of pain in her abdomen and back, 
and on the subsequent days urine, highly 
colored with blood, was discharged by the 
catheter 

On the 2d of July, the sutures were remo- 
ved ; the fistula had disappeared, and the 
woman was discharged a week later, cured. 
On the day of her discharge, she could hold 
the urine four hours, passing it in a full 
stream. I saw her lately, three years after 
the operation, and she stated to me that for 
nearly twelve months subsequent to her cure. 



M. Sghxjppebt on Vesieo- Vaginal Fistula. 



she had suffered from Three to four days 
monthly an intolerable pain in her back, 
which she described as resembling- labor 
pains : then her menses re-appeared and the 
pains left her. She now menstruates regu- 
larly, the blood coming away through the 
nrethia without causing her any inconve- 
nience. 

Case XVI. — Yesico-vaginal Fistula ; trans- 
verse diameter ±o' im ; longitudinal 20 mr ". The 
jfistula cared by eleven silver wire sutures in one 
operation. 

A. S., a native of Speyer, Germany, thirty- 
eight years old, mother of two children, com- 
plained of labor pains on the morning of the 
7th of September, 1864. At 10 A. m., next 
day, the membranes ruptured, and from that 
time to 10 r. 3r., labor pain continued with 
hardly any intermission. Xo apparent pro- 
gress having been made, a doctor was sent 
for, who delivered her with the forceps, at 11 
A. M. of the next day, of a dead foetus. The 
patient, while in the lying-in state, was per- 
mitted to retain her urine for three succes- 
sive days ; when she passed her water, " it 
filled a large water-pot," the patient thinking 
"it would never stop." Two hours from 
that time she observed that the sheets under 
her were wet, and became conscious that the 
urine came through the vagina. The urine 
ceased to be discharged by the natural outlet. 
When examined, the entrance of the vagina 
was found to be occupied by the inverted 
bladder, protruding beyond the labia majora. 
Here the same phenomenon respecting the 
action of the ureters, as described in Case X, 
was observed. The mucous membrane of the 
bladder was in a high state of hyperemia. 
After the bladder had been reduced, three 
fingers could without difficulty enter the 
fistula. At the fundus of the vagina, and to 
the left, were the rudiments of the neck of 
the uterus, forming two small fleshy tumors, 
with an opening between them leading to the 
cavity of the uterus. The fistula occupied 
the greater part of the vesico-vaginal septum, 



extending over the neck of the bladder ; the 
lower border was 25 mm from the orifice of the 
urethra, the upper border running close 
to and partially beneath the uterine frag- 
ments. 

On the 13th of February, chloroform was 
administered, which produced a severe kind 
of trismus. In order to retain the bladder in 
its proper position, sponges were introduced 
through the rent in the bladder — a method I 
have found usefvd in such cases, as it obviates 
the necessity of employing an assistant to 
keep the bladder depressed during the vivi- 
fying of the edges of the fistula, which latter 
process is also greatly facilitated by it. In de- 
nuding the edges of the opening, considerable 
bleeding happened. The fistula was closed 
by eleven twisted silver wire sutures. On ac- 
count of a portion of the upper border of the 
fistula, lying beneath the uterine fragments, 
I was obliged to insert two sutures through 
it, but on attempting to twist them they cut 
through the tissues. By inserting the needle 
higher up, so as to include a larger portion 
of the bladder in the sutures, this was recti- 
fied. The catheter was then applied, and 
kept in the bladder for the following ten 
days. Cold water was injected into the blad- 
der every half hour during two days subse- 
quent to the operation. Though opium had 
not been given, no alvine evacuations took 
place during the patient's confinement in 
bed. 

On the tenth day, the sutures were removed, 
when a complete and firm obliteration of the 
fistula was found to have taken place. Two 
days later the patient was allowed to leave 
her bed. Sitting on a chair, she could retain 
her urine for an hour, when she discharged 
from three to four ounces, through the ure- 
thra. A month afterwards I had occasion 
to examine her again, when I could hardly 
detect the cicatrix. She was able to hold her 
urine nearly two hours, although not so long- 
when in a recumbent position. Laying on 
her back caused the mouth of the urethra to 
gape. 



28 



M. Schuppert on Vesico- Vaginal Fistula. 



Case XVII. — Vesicovaginal Fistula ; trans- 
verse diameter 20 mm ; longitudinal 5 mm ; cured in 
one operation, dispensing with after-treatment. 

A. D., a native of Germany, thirty-eight 
years old, a priniipara, was confined with 
child on the 17th of March, 1865. Her labor 
being very tedious, a physician was sent 
for. Failing to deliver her with the forceps, 
I was summoned to her assistance. When I 
arrived I found the patient nearly exhausted, 
complaining of extreme thirst, and suffering 
greatly. Her abdomen was much distended ; 
pulse frequent and feeble. Finding that the 
woman had an unusually contracted pelvis, 
and. that the foetus" was in all probability 
dead, I did not hesitate in applying the 
cephalotribe, previously administering chlo- 
roform. A profuse haemorrhage ensued after 
delivery. The uterus did not contract. Ice 
was, therefore, applied to the abdomen, and 
ergot given internally. The patient vomited 
a good deal during the day ; the pulse in the 
evening one hundred and sixty and small. 
The application of ice was continued during 
the night, being also given by the mouth. 
The next day the patient suffered much from 
hiccough ; pulse in the evening seventy-five, 
and more full ; great tenderness of the ab Jo- 
men ; the uterus more contracted. Ice was 
continued till the next day. The patient 
recovered gradually, but not without the 
formation of a vesicovaginal fistula. I ope- 
rated upon this fistula three months subse- 
quently. The patient living in very humble 
circumstances, submitted to the operation 
only upon the condition that I would not 
confine her to bed, as she had to attend to 
the wants of her household. I told her that 
I would not vouch for the result, but she 
insisting upon it, I acceded to her request. 
The fistula was closed by five interrupted 
silver wire sutures ; no catheter was applied ; 
no water injections made — she attending to 
her work as usual. I visited her every clay. 
She passed urine frequently, but none came 
away but by the natural outlet. Ten days 
afterwards, when I removed the sutures, 



the fistula was obliterated, and has re- 
mained so. 



TWO OASES OP OBLITERATION OF THE VAGINA. 

Case IV. — Vesico-urethro-vaginal Fistula ; 
introitus vagina; nearly obliterated ; operation 
for total occlusion of the vaginal entrance ; suc- 
cess ; menstruation through the urethra. 

F. M., thirty-four years old, the wife of a 
poor emigrant, arrived here in the month of 
June, 185S. Fourteen days after arrival she 
was for the first time coutined in labor. Not 
having the means to employ either a doctor 
or a midwife, a female friend of hers volun- 
teered in the capacity of the latter. She had 
been nearly four days in labor before de- 
livery of a dead child took place. The child 
w T as born in breech presentation. The urine 
had come away from the vagina since the 
birth of the child. She had experienced a 
great deal of pain after delivery. 

In examining the parts, I found the en- 
trance of the vagina nearly closed. Towards 
the perinium was a semi-lunar opening of 
20""" in length, gaping at the middle of the 
fissure to an extent of four millimetres. A 
male catheter, introduced into the urethra, 
could be brought out through that opening. 
The examination further revealed a large 
destruction. The greater part of the vesico- 
vaginal septum, as also a portion of the ure- 
thra, had been destroyed. Under those cir- 
cumstances, I thought I should be justified 
in making the proposition, to finish what 
nature had already nearly accomplished, the 
entire occlusion of the vaginal entrance. 

I did not meet with any serious objection 
to this course from either the patient or her 
husband. 

On the 14th of August, the bowels having 
been evacuated the day previous, the edges 
of the rent were pared off to the extent of 
5 mm . The abrasion was made with the ut- 
most care in order to preserve as much of 
the thickness of the edges as possible. In- 



M. Schuppisrt on Vesico-Yaqinal Fistula. 



troducing the left index finger into the 
rectum, I made an iucision through the tis- 
sue between the vagina and rectum to the 
depth of l.V ', and of a corresponding length 
with the fissure, taking every precaution not 
to injure the rectum. This was done partly 
to make the posterior portion of the fissure 
more movable, and partly to prevent any 
injurious action of the sphincter and levator 
ani muscles on the edges, when united. In 
the cut so made I introduced a thin plate of 
lead, to prevent too early an union of the 
parts divided. The fissures was then closed 
by five interupted silver sutures. A cathe- 
ter was placed in the urethra and retained 
for ten days, when, after the removal of the 
sutures, the fissure was found to he entirely 
closed. The plate of lead was then removed 
and the wound allowed to heal. The patient 
having lost her husband from yellow fever, 
went to Cincinnati to live with a sister. 
In February, 1S-39, I received a letter from 
her, wherein she stated that she regularly 
menstruated — that the blood passed through 
the urethra, and that she did not experience 
any inconvenience from it. 

There is a case of occlusion of the vagina 
from parturition reported by Dr. T. G. Eich- 
ardson, in the New Orleans Medical and Sur- 
gical Journal, March, 1861, a part of which I 
will copy: " Sarah, aged 20, a mulattress, 
the property of Mr. D. of this city, admitted 
in Stone's Infirmary, November 29th, 1859, 
was confined twelve months previously, 
when, from some cause or other, it became ne- 
cessary to remove the child by cephalotomy. 
Inflamation and sloughing of the interior 
of the vagina followed upon the operation, 
and the result was complete closure of the 
canal. Upon examination, I found the clo- 
sure to begin immediately behind the lesser 
labia, the parts being here drawn closely 
together to form a small puckered cicatrix 
not more than a third of an inch in diameter. 
There was evidently an accumulation of 
menstrual fluid in the uterus, the tumor 
being clearly distinguished above the pubis 



and distinctly felt by the linger inserted into 
the rectum. By the latter procedure, aided 
by a catheter in the bladder, I also ascer- 
tained that the occlusion occupied nearly or 
quite the whole length of the vagina, as the 
tumor formed by the accumulated fluid de- 
scended into the pelvis but little lower than 
the normal situation of the os tinea?, and 
below this point the finger and the catheter 
were separated by a septum of firm tissue, 
judged to be not more than half an inch in 
thickness." It may be stated here, though not 
pertinent to otu- purpose, that Dr. Eichard- 
son established a permanent opening of the 
vagina. 

This case is the more remarkable, as by the 
extensive "sloughing of the interior of the 
vagina," neither a. recto nor vesico-vaginal 
fistula was established. Is it not singular 
that the operation to procure an artificial 
obliteration of the vagina should in general 
be so unsuccessful 1 

Dr. G. Simon, in Darmstadt, Germany, 
has tried a new method to obliterate the va- 
gina, to which operation he has given the 
name of " Gross- Obliteration of the Vagina." 
This method consists in bringing the remains 
of the vesico-vaginal wall into union with 
the recto vaginal wall in a transverse direction. 
Simon recomencls this operation in cases where 
the fistulous openings are so large that they 
cannot be closed by sutures. A necessary 
condition for the successful employment of 
this method consists in the urethra remain- 
ing, so that the upper part of it can be fresh- 
ened for a space of from two to three centi- 
metres. On the same level with the 
excision of the mucous membrane of that 
organ, a similar portion is cut out in a 
circle from the sides and posterior Avail of 
the vagina. The apposition of the wound 
is effected by six or seven strong silk sutures. 
Simon thinks that his method posesses great 
advantages over the operation of episior- 
raphy and transplantation ; that it promises 
greater certainty in healing, being free from 
danger, prevents incontinence of the urine, 



30 



M. Schuppbbt on Vesico- Vaginal Fistula. 



preserves a portion of the vagina, and exerts 
no bad influence afterwards 

He has performed this operation in sis cases 
(the first case is reported in DeutcheKUnik, 
of 1858, and was performed in May, 1855). 
Though he was not successful in obtaining a 
perfect cure, yet he met with so much suc- 
cess as that only a very small fistula remained. 
(But the smallest fistula remaining of 
course renders the effect of the operation 
nugatory.) 

This method has also been tried by Dr. 
Eoser, in Marburg, with partial success. Dr. 
Werner, in G-iesen , has cured one case completely. 
The patient was discharged from the hospital 
in August, 1857, six months after the opera- 
tion. 

Another case, though not published yet 
to my knowledge, is mentioned by Dr. Boze- 
man. ( Neic Orleans Medical and Surgical 
Journal, for 1860, January number, page 57.) 
The obliteration in this case was obtained 
by uniting the posterior with the anterior 
wall of the vagina just below the vesical 
extremity of the urethra, and within the 
meatus urinarius. Dr. Bozeman probably 
not being aware of Simon's operation, says: 
"This case occasioned the inauguration of a 
new and successful plan of treatment, never 
before adopted that I am aware of," and 
"the operation can not be regarded otherwise 
than as a great triumph. It enables us now 
to manage a class of cases, if not as satisfac- 
torally as we could desire, certainly upon 
scientific principles, and with results never 
heretofore attained." 

Case XIII. — Urethro-vesico-vaginal Fistula; 
destruction of nearly the whole anterior surface 
of the vagina, including bladder and urethra ; 
the inner opening of the urethra obliterated; 
Elytro-cpisiorraphy; success. 

This case occurred in the person of a young 
negro woman, about sixteen years old, a slave 
of J. M. P — , of Bayou Sara, La. She was 
admitted into the Infirmary April 5th, 1861. 
The entrance of the vagina being very nar- 



row, it was dilated by the introduction of 
sponges. On the second day after this, the 
patient complained of great pain in the hy- 
pogastric region. The sponges being remo- 
ved, the vagina was found dilated to a great 
extent, but was also considerably excoriated, 
blood exuding from its surface. This was 
caused by the pressure of the sponges, which 
had become impregnated with decomposed 
urine. The speculum revealed not only the 
magnitude of the destruction, but the impos- 
sibility of effecting a cure by our method, from 
a sheer want of material. All that was left of 
the anterior wall of the vagina consisted of a 
space of twenty millimetres, containing the 
urethral canal, the inner orifice of which 
was found closed and closely adhering to the 
symphysis pubis. The occlusion of such an 
enormous gap by sutures was therefore en- 
tirely out of the question. 

I was at a loss how to proceed in order to 
relieve the patient from her misery. The 
only thing which was clear, was, that she 
must be relieved in some way or other. A 
transverse obliteration of the vagina coidd 
not be thought of, because the anterior por- 
tion of the vagina, with the greater part of 
the urethra, was gone. Nothing' therefore 
was left but to try the obliteration of the 
vagina by Episiorraphy — an operation which 
was first proposed and twice executed by 
Vidal de Cassis, and by which that surgeon 
gained nothing but universal condemnation; 
and why? Because he was unsuccessful. 
Nevertheless, I resolved to try it, though the 
history of the operation was but a record of 
failures. After the patient was brought un- 
der the influence of chloroform, the urethra 
was opened with a trocar and a catheter intro- 
duced. The mucous lining of the labia ma- 
jora was then sufficiently removed, the "dulce- 
dones amoris" ornympha3 cut entirely away, 
and the introitus vagina?, to an equal length 
with the remaining portion' of the urethral 
wall, was vivified circularly. The bleeding 
which ensued was considerable. After it had 
subsided, the denuded parts were brought in 



M. Schuppekt on VesiefhYqginat Fistula. 



31 



contact by the application of seven interrupt- 
ed silver "wire sutures, which were fastened 
by broad clamps of lead on the outside of 
the labia majora. 

Deeming- it of importance, I will give here 
minutely the modus operandi : The woman 
was placed on her knees, whilst her abdomen, 
chest and head were supported by pillows. 
In paring the inner part of the labia majora, 
removing the nympluv to a level with the 
denuded surface of the labia majora, and 
vivifying a circular part of the entrance of 
the vagina to an extent of two centimetres, 
I had obtained a surface which, when agglu- 
tinated, woidd measure from four to five cen- 
timetres in depth. Entering now the long 
flexible needle from outside the lower vivi- 
fied border of the right labium majus, in a 
horizontal line with the meatus urinarius, I 
thrust it in and back through the tissues, till 
its point came out in the centre of the poste- 
rior wall of the urethra, just above the 
meatus urinarius. A silver wire was theu 
introduced into the eye-hole of the needle 
a ad the latter withdrawn, leaving the other 
end of the wire in the vagina. The needle, 
freed from the thread, was then inserted 
again in the left labium majus in a corres- 
ponding place with that of the right labium, 
thrust through the tissues, and brought out 
at the same point where the wire was hang- 
ing out of the urethral wall. This end of the 
wire was now carried through the eye-hole of 
the needle. In withdrawing the latter, I had 
formed a loop which, when tightened, would 
include a depth of at least four centimetres. 
Three sutures were in this manner applied, 
each of them going through the posterior 
wall of the urethra. The other four sutures 
were placed at proper distances, reaching on 
each side above the denuded surface of the 
vagina. All the sutures were then secured 
outside the labia majora, over broad leaden 
clamps, by perforated shot. 

In order to test the efficiency of the sew- 
ing, a large quantity of water was injected 
through the catheter. Xo fluid escaped but 



I by the catheter. The patient had a slight ac- 
celeration of the pulse during the night, but 
did not complain otherwise. Ko untoward 
accident happening, the sutures were removed 
on the fourteenth day after the operation, and 
the obliteration was found to be accomplish- 
ed. The woman was kept in bed during the 
following week, and then the permanent ap- 
plication of the catheter dispensed with, but 
she was ordered to introduce it every two or 
three hours. She could retain the urine for 
that length of time, when in a recumbent 
position. When first allowed to leave the 
bed and to walk, I observed to my satisfac- 
tion that only a few drops of urine occasion- 
ally came away, while at the same time the 
catheter yielded a quantity of from three to 
four ounces. The patient remained at the 
Infirmary until the 11th of July, by which 
time her condition had not altered in any 
respect. At her discharge, three months after 
the operation, a catheter was given her, with 
the advice to use it several times a day, and 
not allow the urine to collect in her bladder. 
I have not heard from her since. 

Remarlcs. — The existence of a sphincter 
muscle of the urethra has not yet been pro- 
ved ; the contractile fibres contained in the 
cellular tissue may, by the adjunctive action 
of Wilson's urethral muscle, prevent the in- 
voluntary discharge of urine, even though 
(as in the present case) a portion of the ure- 
thra had been lost. 

This is, to my knowledge, the only case on 
record where the operation of episiorrapky 
has been crowned with success. It had 
failed with Vidal de Cassis, Velpeau, Dieffen- 
bach, Berard, Wutzer, Simon, Eoser and 
others. In some of the reported cases, oblit- 
eration was obtained, but always with the 
exception of a small opening, situated in 
most cases behind the urethra. The only 
case in which the operation was called 
"successful," is reported by Massonneuve 
(Memoires de la SociiU de Chirurgie de Paris, 
torn, III, p, 226); but the success was unfor- 
tunately proved by a post mortem examina- 



3: 



M. ScilUPPEET on Vesica- Vaginal Fistula. 



tiou — the patient having' been carried off by 
phlebitis before the cure was accomplished. — 
Massoimeuve,hi his case, obliterated not only 
the vagina, but also the urethra, and in 
order to get an outlet for the urine, he tried 
to establish a recto-vaginal fistula. Being 
unsuccessful here, he perforated the pe- 
rinaeum. with a trocar, intending to apply an 
obturator afterwards. Pending the accom- 
plishment of this original and curious idea, 
his patient died from phlebitis. 

A. Berard, in 1844,. almost succeeded in 
this operation, " only two small openings 
being left," but the patient died of perito- 
nitis three weeks afterwards. This case was 
brought before the Academy of Sciences, and 
during their deliberations, three more cases 
were operated upon. The discussion did not 
result in favor of the operation. The accou- 
cheurs were nearly all opposed to it (as a 
matter of course). The chief objections 
urged against it were : 1st, that a perfect 
obliteration was impossible ; 2d, the opera- 
tion was dangerous ; and 3d, that in case the 
operation should be successful, the patient 
would be placed in a miserabble condition 
ever afterwards. 

While I do not pretend to assert that the 
method of cross-obliteration should not be 
preferred to episiorraphy, whenever the cir- 
cumstances are favorable for its performance; 
yet, in a case like the above, it seems to me 
that no alternative is left, except trying to 
ameliorate the condition of the patient by 
the operation of Blytro-episiorraphy. 

Resume. — Of these seventeen cases, the 
labor-pains lasted from twenty-seven hours 
to seven days ; seven were delivered by in- 
struments ; in ten, no instruments were used. 
The fistulas were established from the time 
of confinement until eight days after deliv- 
ery. In thirteen, it occurred in the first 
labor ; in one, at the second ; in two, at the 
third ; in one, at the tenth. Three fistulas 
were caused with the foetus in breech 
presentation. The age of the women varied 



from fourteen to thirty-eight years. Two 
died — one from pyaemia, the other from 
phthisis. All the others were cured, two of 
them by obliterating the vagina. 

At the close of the publication of these 
cases, I feel bound to acknowledge the valu- 
able services of Drs. Choppin, Eiland, Gold- 
mann, Grail (since dead), Kattmauu, Lceber, 
Maas, Schmittle and others, but most so of 
my friend, Dr. M. A. Dauphin, to whom I 
feel specially indebted, not only for the en- 
durance and patience with which he assisted 
me in the majority of the cases here des- 
cribed, but for the skill wit'i which he has 
executed the accompanying drawings. 



G. History of the Operation. 

There can not at this day exist a doubt, 
that the happy results so lately obtained in 
the treatment of fistulous openings, com- 
prising the bladder, urethra, uterus, rectum, 
and vagina, are in the main due, 1st, to the 
manner of obtaining access to them ; 2d, to 
a sufficient denudation of the borders ; and 
3d, to the proper application of metallic 
sutures. In the advocacy of these means, 
American surgeons occupy a very prominent 
position. 

It can not be without interest to compare 
the results obtained on this continent, with 
those of other nations. But in looking over 
their records, it is not my purpose to notice 
all the abstract propositions, singular manip- 
ulations, and curious instruments invented 
and advocated, as they seem only to demon- 
strate their own impracticability and to in- 
crease the museum of curiosities in the art 
of healing. So far as the operations for this 
class of diseases pjossess an intrinsic value, 
or represent the standard to which surgery 
has gradually advanced in the different 
countries, they will find a place here. 

In turning over the leaves of the records 



M. Schtjpper'I on Ve&ico'-Vaqinal Mshila. 



33 



of those nations who claim each to be in 
advance of the others and the rest of man- 
kind — glorious France, learned Germany, and 
industrious England — we will be able to 
judge what they have accomplished towards 
the cure of vesico-vaginal fistula. Let us 
look first at the men of great genius in 

FRANCE. 

Ambrose Pari, 1570, proposed a retinacu- 
lum to close vesico-vaginal fistula. 

Dcssav.lt, 1801, advanced only so far in the 
treatment as to approximate the edges of the 
fistula by introducing a large conical plug 
into the vagina to reduce the fistula to the 
condition of a transverse cleft, retaining a 
catheter in the bladder permanently. 

LaUema/nd, 1825, cauterized the edges of 
the fistula with nitrate of silver, and applied 
inside the bladder a catheter armed with 
hooks, which instrument he called "sonde 
airigne." With these hooks he retained the 
edges of the fistula in contact. Of 15 cases 
so treated, 4 were cured, 2 improved, 6 were 
failures, and 3 died. 

Dupuytren invented an instrument sim- 
ilar to that of Lallemand. Besides, he first 
proposed and used the actual cautery, kept 
a catheter in the bladder, and is said to have 
finally cured some cases. 

JRoux, in 1829, tried the "suture entortillse" 
with ordinary thread and additional metalic 
bars, after having pared the edges. One 
operation took up two hours, and the patient 
died on the tenth day. 

Tidal de Cassis (in his Pathologie Externe), 
says: "I do not believe that there exists in 
the science of surgery a well authenticated 
complete cure of vesico-vaginal fistula, a 
fistula due to a loss of substance from the 
bas fond of the bladder. 

Nklaton, in 1852, says he has seen some 
cases getting well without an operation ; he 
is, therefore, in favor of waiting, and in case 
an operation should be necessary, he says he 
would try autoplasty or the electric cautery. 
Velpeau, in his Operative Surgery, says, 



"The suture, which must have first suggested 
itself to the mind, is of such difficult applica- 
tion, that but few practitioners have ventured 
to make a trial of it ; so that scarcely any 
mention is made of it in the works that have 
issued from the school of Paris. To abrade 
the borders of an opening, when we do not 
know where to grasp them ; to shut it up by 
means of needles or thread, when we have no 
point apparantly to secure them ; to act upon 
a movable partition placed between two cav- 
ities, hidden from our sight, and upon which 
we can scarcely find any purchase, has ap- 
peared to be calculated to have no other 
result, than to cause unnecessary suffering to 
the patient. 

Job. de Lamballe tried first aplastic opera- 
tion, naming it "Elytroplasty," in which he 
borrowed flaps from the labia majora, and 
nates. After having given up that method, 
of which Malgaigne, in 1850, said, " This 
proceeding is at the present time that, which 
has procured the most numerous and lasting 
successes." Jobert invented another method, 
to which he assigned the ponderous name, 
"Keunion autoplastic par glissement." Jo- 
bert being the most successful surgeon in the 
treatment of vesico-vaginal fistula amongst 
his countrymen, I will give his method 
here in an abbreviated form : The patient 
being placed in the position of lithotomy, 
the labia majora are pushed outside by as- 
sistants, the recto-vaginal portion beiug de- 
pressed by a hook. Then the colln.m uteri is 
dragged down by Museux's sharp hooks to 
a sufficient distance beyond the vulva, to 
bring the fistula in view. By a cut of the 
bistoury in a semi-circular form, the vagina 
is separated from the neck of the uterus to a 
length of one inch. The edges of the fistula, 
are then denuded, brought in contact and 
united by double silk threads or small tape 
carried through vagina and bladder. After 
a reposition of the parts pulled down, apiece 
of pyrotechnical sponge is kept in the vagina, 
to absorb the blood, and an elastic catheter 
introduced into the bladder. After twentv- 



34 



M. Schuppeet on Vesico-Vaginal Fistula, 



four or forty-eight hours, the sponge is re- 
moved. On the sixth to the eighth day an 
inspection is made, the sutures are removed, 
the catheter is re-applied, and on the twenti- 
eth day the patient is "discharged as cured." 
Jobert reports 16 cases operated upon by 
this method, out of which 11 were cured, in 
one the cure was incomplete, in another a 
failure, and three died. 

Malgaigne, in speaking of the application 
of sutures in this operation, remarks, " It 
will he seen that this point of surgery re- 
quires fresh researches. Paring the edges 
may he done in longititudinal fissures with 
scissors. To refresh the edges of transverse 
fistulas we have only caustics, particularly 
nitrate of silver, which is proposed by Mr. 
Lallemand as the general application." Mr. 
Malgaigne does not forget to sneer at the 
success of American surgeons in the treat- 
ment of that disease, so long the opprobium 
of surgery. 

To judge from a discussion held at the 
Sock'te de Chirurgie de Paris, September, 
18G2, in which MM. Baneau, Berard, Ver- 
neuil, Mar, Jolin and Depaul participated, it 
seems that even at this late date, the progress 
made in France in the treatment of these 
fistulas consists mainly in the recomenda- 
tion of the use of the nitrate of silver, ("a 
remedy as old as the hills") and in keeping 
a catheter in the bladder ; and because 
some spontaneous cures have been observed, 
it was thought that even the use of the 
catheter might be dispensed with. Since 
the appearance of the two distinguished 
American surgeons, Bozeman and Sims, in 
France, these views, I believe, have been 
partially changed. 

GERMANY. 

The first operation for vesico- vaginal fistula 
amongst the German surgeons has reference 
to a proposition made as far back as 1660, 
by H. von Roonkuyze, in his Heelkonstege 
Anmerk: Amsterdam, 1663. Eoonhuyze re- 
commends the use of a speculum, paring off 



the edges of the fistula, and trying union by 
the first intention by the use of a kind of 
needle made from the quills of a swan (a 
proof that he never tried his own proposi- 
tion). In 1720 we hear from Voelter in Wur- 
temburg. He recommended the interrupted 
suture and the use of a catheter ; the sutures 
to be of silk or hemp, and applied with 
needles and a needle-holder. Of his method 
he said, " The operation may appear to some 
to be curious and too delicate. This can not 
be denied ; but I have tried it in a woman 
of the better classes, though I have failed." 
From that time all is silent in Germany, until 
the celebrated obstetrician, Naegele, inWur- 
temburg, about the year 1812, brought the 
matter again before the profession. 

Naegele proceeded in the following manner: 
Placing the patient in the position for lithot- 
omy, he passed a catheter through the ure- 
thra into the bladder. He then examined 
with the index finger the extent and form of 
the fistula, as also the character of its edges ; 
with a pair of sharp pointed scissors or a 
knife, introduced into the vagina and covgred 
with his finger, he next scarified the edges 
of the fistulous aperture. He did not use a 
speculum, but trusted entirely to the experi- 
menting finger. It is easy to foretell the re- 
sults of his operations. He united the edges 
with small tape and the interrupted suture, 
and made also use of curved needles from 
silver, gilded, and the sutura circumvoluta. 
Hot satisfied with his results, he invented 
different machines, too complicated and im- 
practicable to be described here. 

Schreger,mlS17 , made some improvements. 
He placed the patient on her belly ; with 
scissors he scarified the edges of the fistula, 
uniting them with interrupted silk sutures. 

Ehrmann made \xse of his three-branched 
speculum, curing a case with the interrupted 
suture. 

Wutzer, in Bonn, in 1838, placed the pa- 
tient on her belly ; the perinseuni was raised 
with a hook by an assistant ; the labia niajora, 
together with the sides of the vagina, were 



M. SenrrPEKT on Vesica- Vayinal Fistula. 



3>S 
o 



drawn outwards by assistants. He then 
ed with a sharp hook the mucous nieru- 
brane of the vagina around the fistula, cut- 
ting- it oli' with the scalpel to the breadth of 
three to four lines. The wound was closed 
by the insertion of long- insect needles, placed 
from three to four lines distant from each 
other, and the sutura circumroluta. He 
avoided piercing the mucous membrane of 
the bladder, but advocated the puncture of 
the bladder above the os pubis, for the appli- 
cation of a catheter to carry off the mine. 
After the operation he placed the patient on 
her belly in bed, and in order to keep her in 
that position she was properly buckled with 
straps. He removed the needles on the third 
or fourth day. Chelius speaks thus of Wut- 
zer : " He has had the greatest success ; of 
eighteen cases operated on, three were radi- 
cally cured, and the rest improved. By the 
careful and precise detail of his observations 
and trouble, accompanied with a rare perse- 
verance, he has contributed greatly towards 
perfecting the operation, and by the addition 
of paracentesis vesicre in order more com- 
pletely to draw off the urine, has advanced 
considerably further than his predecessors. 
The performance of the operation for vesico- 
vaginal fistula is always difficult, and may 
be even dangerous, from severe inflammation 
of the bladder and peritoneum." 

Chelius. — But what is Chelius' favored 
method of treating these fistulous openings 1 
According to a letter sent to Dieffenbach by 
him, in 1844, it consists in nothing more nor 
less than the extensive application of the nitrate 
of silver. " The more surface," he says, " you 
are able to cauterize, the better the result." 
Chelius does not think the catheter to be of 
any value. Of sutures he does not speak 
favorably, saying, " The cure of a fistula by 
their use will rarely if ever be effected in one 
operation, or a real agglutination of the 
edges be obtained. The sutures, one or all, 
will cut through the tissues ; the urine, by 
infiltration, will destroy agglutination ; the 
edges will gape as before, and only by a 



subsequent suppuration and repeated cau- 
terizations will the fistula become smaller or 
be obliterated. 

Kilian, after using blunt hooks to dilate the 
vagina with, and introducing a silver male 
catheter through the urethra into the bladder, 
in order to bring the edges of the fistula 
better in view, he vivified the margin of the 
fistulous opening by cutting out a funnel- 
shaped piece, and closed the wound with the 
interrupted suture. 

Dieffenbach placed the patient in the posi- 
tion for lithotomy ; a silver catheter was 
introduced into the bladder and held by an 
assistant, and the vagina dilated by different 
hooks, which were held by other assistants. 
If the fistula was situated high up in the 
vagina, he inserted a pair of hooked forceps 
into the wall of the vagina, above the fistula, 
and a second one beneath it, by which the 
vagina was drawn down till the edges of the 
fistula appeared between the nynrpha?. The 
edges of the fistula were then taken up with 
a conjunctival hook, and a small scalpel 
thrust through the tissues between vagina 
and bladder, half a line deep. The vaginal 
portion was then removed, by which the 
outer opening of the fistula became larger 
than the inner one. The mucous membrane 
of the bladder was left untouched. In small 
fistulas, where the separation of the two 
walls was considered unnecessary, a funnel- 
like piece was cut out. In applying the su- 
tures in small fistulas, Dieffenbach used a 
strong curved needle, furnished with a silk 
thread, and held by a needle holder. The 
needle was inserted from two to three lines 
from the edge of the wound. Piercing the 
mucous membrane of the bladder was care- 
fully avoided. After all the sutures were 
placed, the wound was cleaned, dried, and 
painted over with a diluted tincture of can- 
tharides ; the sutures were then tied by a 
double knot and cut off. The vagina was 
syringed with cold water, dried with sponges 
and filled up with charpie, when wine was 
injected to saturate the charpie. A male 



36 



M. Schuppert on Vesico- Vaginal Fistula. 



catheter was introduced through the urethra, 
the patient placed in bed on her back, and a 
glass placed between her thighs to collect the 
urine. Cold water had to be injected in the 
bladder several times daily. On the third 
day the charpie was removed, the vagina 
washed out, and refilled with charpie. This 
was repeated several times, when the sutures 
were removed. The catheter remained in 
the bladder till the eighth day, when the 
patient was allowed to pass the urine uncon- 
trolled. The patient was then allowed to 
leave her bed, cured. " This is the proceed- 
ing of a lucky case," says Dieffenbach; "but 
if the sutures have cut through, which hap- 
pens mostly on the third or fourth day, the 
operation has to be renewed at a later day." 
Tn larger fistulas, Dieffenbach used sutures 
made of three to four threads, placing them 
at a distance of two lines from each other. 
"The difficulty of obliterating a large fis- 
tula," says Dieffenbach, "increases with the 
distance from the introitus vagina." In cases 
where the vagina could not be brought down 
by hooks, he used Bicord's two-valvular 
speculum. Of fistulas with the long axis in 
a transverse direction, Dieffenbach finds the 
operation still more difficult, and gives the 
advice, wherever it could be done, to trans- 
form a transverse into a longitudinal one. (!) 
In desperate cases, where Dieffenbach could 
not hope for a favorable result by using 
sutures, he advocated the actual cautery, 
saying, " The more desperate the case, the 
more strongly is the use of the cautery indi- 
cated, and the result often the more surpris- 
ing." What Dieffenbach means by despe- 
rate eases we can not define, because on 
another page (551) of his valuable book on 
Operative Surgery, he says, "Still less, as in 
small fistulas, can we expect from the use of 
caustics or the ferrum cande^s in fistulas 
with great defects, where the edges are usu- 
ally thin and attenuated." As to the cause 
of the unsatisfactory results so often obtain- 
ed by the application of sutures, Dieffenbach 
says, "The sutures either cut all through one 



of the edges, from the second to the fifth day, 
or they cut through both edges alternately, 
and these cuts do not unite again as in other 
wounds. But more commonly does it happen 
that mortification takes place around the 
stitches in the mucous membrane of the va- 
gina. Some of the sntures cut through, urine 
leaks out, incrustating the mortified spots 
and sutures, and when the sutures are remo- 
ved the fistula is larger than before. The cure 
of vesico-vaginal fistula is one of the most 
difficult operations in surgery. With grief 
do we look at the imperfection of our art, ac- 
cusing it and good mother Nature for their 
insufficient assistance. For centuries re- 
searches have been made for new and sure 
methods, because the old ones have proved 
to be worthless ; and with shame have we to 
acknowledge that the progress we have made 
is but small. The cure of vesico-vaginal fis- 
tula is still of a rare occurrence, at least more 
rare than its failure. Over sangirine in seeing 
once a fistula of a great extent successfully 
obliterated by eight sutures, I was full of hope 
now to be able to defeat the grim enemy for 
ever ; but then I saw a small needle-hole re- 
maining after an otherwise successful opera- 
tion, or a fistula not larger than the point of 
a probe, defying all efforts to close it; I saw 
a fistulous opening of the size of a small pea, 
after cutting, sewing, cauterising, attain the 
extent of a large pea, a hole of 5 mm diameter, 
getting as large as one centimetre, and in- 
creasing from one centimetre to two centi- 
metres ; then I stopped. I have operated on 
a woman eighteen times, and discharged her 
unrelieved. I have gathered together large 
rooms full of these unhappy women from 
all parts of the country, and I have exhaust- 
ed all resorts and have cured only a few." 

J. v. Metzler, of Brag, a cotemporary of 
Dieffenbach, published in 1846, in the Brager 
Viertel Jahresschrift, a treatise under the 
title " Bathology and Treatment of Urinary 
and Vesico-Vaginal Fistulas, with a Method 
of Treatment easily executed and completely 
successful," in which he says, " To perform 



M. Schuppert oh Vesica- Vaginal Fistula. 



the operation successfully, it is of much im- 
portance to have — 1, A speculum, serving as 
a dilator of the vagina. Such an instrument 
consists of a grooved conical blade, live and 
a half inches long', three inches wide at the 
anterior part, one-half of an inch wide at the 
posterior. The end of the speculum is bent 
under a right angle, and protected with wood 
for the handle. The instrument is best when 
made of silver, and polished to reflect the 
light on the parts to be operated upon. [Ex- 
actly the instrument recommended by Sims.] 
2, An apparatus consisting- of perforated 
clamps, gilded needles, and an instrument 
called ' Eosenkranz werkzeug,' consisting of 
perforated balls of the size of large shot, by 
which the clamps are held in contact." His 
modus operandi he describes in the following 
manner : "After the patient is placed on her 
knees and elbows, the dilator is introduced 
into the vagina and given to an assistant, 
who in holding it presses it against the 
rectum. The edges of the fistula are then 
pared off, which may be accomplished with 
curved scissors. One line and a half from 
the mucous membrane of the vagina and half 
a line from the edge of the bladder have to 
be cut off ; the needles are then applied, and 
the wound held in coaptation by the clamps ; 
a female catheter is introduced into the blad- 
der by the urethra, and the catheter fastened 
by a T bandage." Dr. Sprengler, in his re- 
view in Canstatt's Jahresbericht, 1846, says, 
that in six cases operated on by Metzler, the 
results have been more favorable than with 
any other known method. If we exchange 
the Eosenkranz werkzeug with split shot, and 
the needles with silver wire, we have exactly 
the method in all its details, and the materials 
recommended by Sims and so successfully 
made use of in this country. Metzler may 
thank the prejudice of his countrymen that 
the triumph of having initiated so valuable 
an improvement has been carried off by 
others. It is nearly twenty years since 
Metzler published his method, and for the 
first time introduced this most valuable im 



provement — the speculum — which enables 
the surgeon now to undertake the operation 
for vesico- vaginal fistula with a great hope of 
success ; and yet, at the present day, we see 
G erman surgeons grapple with the difficulties 
to get access to the fistula, following Jobert 
de Lamballe in dragging down the vagina or 
uterus with sharp hooks. 

Simon, in Darmstadt, has probably opera- 
ted more successfully for the cure of vesico- 
vaginal fistula than any one else in Germany; 
and his method being generally adopted 
there, I will give here a synopsis of it : 

Simon's Method. — If the seat of fistula is 
high up in the vagina, he uses sharp hooks 
inserted in the uterus to pull down the vagina 
and to bring the fistula in sight, or he makes 
use of Dupuytren's speculum. In fistulas 
easier of access, the vagina is dilated with 
levers or the fingers of assistants, and by 
the additional introduction of a catheter in 
the bladder, he brings the edges of the fistula 
better into view. The edges of the fistula- 
are then pared off, including a portion of the 
mucous membrane of the bladder. For 
sewing up the pared edges, he uses a double 
row of interrupted silk sutures. In order to 
keep the edges better united, the exterior 
row, made from double silk thread or tape, is 
applied to assist the main sutures, which are 
placed from one to one and a half lines distant 
from the vivified borders This inner row of 
sutures is carried through the edges, care 
being taken to avoid the mucous membrane of 
the bladder, whilst the exterior row of sutures 
is carried through the whole thickness of the 
Madder. (!) These exterior sutures are so 
placed that each of them is between two of 
the main sutures. The exterior ligatures are 
commonly found to have cut through from 
the fifth to the seventh day, during which 
time the wound is closed. Of 19 fistulas so 
operated upon, 10 were perfectly cured, 5 
incompletely, 1 discharged incurable, and 3 
died. 

Seanzoni, in his " Treatise of the Sexual Or- 
gans in the Female, Vienna-,1857, ''in speaking 



■> o 
.JO 



M. SchtjppERT on Vesica- Vat/hud Fistula. 



•of Simon's method, says, " The method as 
proposed by Simon, and performed in several 
cases with the most favorable success, is in 
respect to its surety and simplicity far above 
all others." 

ENGLAND. 

The history of surgery in Great Britain 
shows that, until recently, but little attention 
has been given to this subject by its distin- 
guished men. John Hunter, Percival Pott, 
Ch. Bell, Astley and Sam. Cooper, Aber- 
nethy, counted amongst the greatest sur- 
geons of the eighteenth century, do not even 
mention the disease in their writings, and in 
the nineteenth century it does not fare much 
better. 

Liston, in his "Practical Surgery" (1846), 
says, " In fistulas of great extent, some ap- 
paratus may be fixed to the pudendum, to 
collect the secretions, and this is in many 
cases all the relief that can be afforded. In 
less severe cases, time and the heated iron 
may accomplish a cure. Attempts have been 
made, by paring the edges of the opening 
and introducing sutures, to induce the aper- 
tures to close ; but little benefit, I have reason 
to believe, has followed this operation." 

Dever employed the actual cautery, su- 
tures and plastic operations, but with little 
success. 

W. Fergusson, like Bransby Cooper, has had 
no experience with the disease. 

F. Miller, in his " Practice of Surgery," 
1852, speaking of vesico-vaginal fistula, re- 
marks, "It is quite possible to dilate the 
vagina so as to expose the injured parts; to 
pare the edges of the opening by a bistoury 
in situ, or after bringing them down exter- 
nally by traction with the vulsella, to effect 
approximation by suture, and to leave a 
catheter in the urethra, so as to conduct off 
the urine before it distends the bladder. 
Sometimes, however, the catheter can not be 
tolerated, and then the prospect is less hope- 
ful. All this can be done with difficulty to 
the operator and pain to the patient ; but a 



successful issue is extremely improbable ; 
and so discouraging has been the result of 
such attempts hitherto, that many surgeons 
are agreed in the propriety of treating most 
cases of severe vesico-vaginal fistula by pal- 
liative means only." 

Syme, in his " Principles of Surgery," 185G, 
is very particular in giving the directions for 
introducing a catheter into the female ure- 
thra, but of vesico-vaginal fistula and its 
treatment he does not say a word. 

Frichsen, in his " Science and Art of Sur- 
gery," 1858, in speaking of the treatment of 
vesico-vaginal fistula, refers to the operations 
of Sims in America, though he himself seems 
to have had no experience in it. 

There can not exist a doubt, in Great Bri- 
tain, that the recent success in the treatment 
of this disease dates from the introduction 
of the "American method." 

J. Y. Simpson, of Edinburgh. His plan of 
operating is based on Bozeman's method (in 
America), though he claims to have made 
some very important improvements on it. 
These improvements consist, according to 
Simpson's statement, in substituting the an- 
nealed blue iron wire, a, hollow needle, and a 
splint made of wire. How essential he thinks 
these improvements, maybe judged by what 
he says in reference to an observation made 
by Dr. Francis, of New York, of what had 
been, or rather had not been, accomplished 
by other nations in curing the disease in 
question. "But perhaps," says Simpson, 
" Dr. Francis maybe induced to recall his 
observations when he comes to know the ad- 
vantages which the iron wire thread sutures, 
the hollow needle and the splint of wire 
present in facilitating the operation and se- 
curing for it a successful result." Now we 
may well leave Dr. Simpson in the enjoyment 
of his improvements, but we do not think 
that we will ever have an occasion to try 
either the one or the other of his improve- 
ments, even should we fail in accomplishing 
a cure with the means in our possession. 

J. B. Brown, senior Surgeon to the London 



M. Schuppekt on Vesico-Vaginal Fistula. 



30 



Surgical Home. In the September number 
of the London Lancet, 1S58, we find two cases 
of vesieo-vaginal fistula, operated upon by 
Dr. Brown, according- to the method of Boze- 
man; both cases were cured. Of the first 
case he says, that he had already operated 
on the patient sixteen times, and had tried 
almost every operation recommended. The 
second was cured by two operations, by 
employing the same method. In 18G3, Dr. 
Brown read before the Obstetrical Society of 
London, a paper on vesico-vaginal fistula, in 
which he stated the results of 55 cases ope- 
rated upon at the Surgical Home. Of these 
55 cases, 43 were cured : 1 much relieved ; 5 
not cured : 4 still under treatment ; and 2 
died. Of the 43 cured, in 24 the result fol- 
lowed the first operation ; in S the cure was 
accomplished after the second operation ; in 
5, after three operations ; and in G, in more 
than three operations. One case died of 
pyaemia on the seventh day after the opera- 
tion. The paper contained besides some other 
valuable observations. Of the number of 
cases specified, 47 had been over twenty-four 
hours in labor ; 39 over thirty-six hours ; 7, 
two days ; 1G, three clays ; 3, four days ; 2, 
five days ; 2, six days ; 1, seven clays. In the 
whole number of 5S cases (three of which 
happened in private practice), instruments 
were used in 29 — exactly one-half of the whole 
number ; and in four of these the labor was 
of less than twenty-four hours duration ; and 
with seven exceptions the patients had been 
thirty-six hours or more in labor before in- 
struments were used. Of the 58 cases, in 24 
only the injury happened at the first labor ; 
in 7, at the second ; in 5, at the third ; in 4, 
at the fourth ; in 6, at the fifth ; in 2, at the 
sixth ; in 5, at the eighth ; in 1, at the ninth ; 
in 1, at the thirteenth ; in 1, at the fifteenth ; 
in 2, not mentioned. In many of these cases, 
notwithstanding the existence of the fistula, 
the patient bore several children before com- 
ing under treatment, while in others children 
have since been born without the recurrence 
of the fistula. 



From the foregoing statistics, Brown says, 
" It is evident that the cause of the lesion is 
protracted labor, and not the use of instru- 
ments or deformity of the pelvis ; and as a 
necessary conclusion, it follows that vesico- 
vaginal fistula would scarcely or never occur 
if labor was not allowed to become protract- 
ed." It is not protracted labor, but rather 
labor with protracted impaction, which has 
to be considered as the cause of the mischief; 
otherwise, I fully concur with Brown, and 
am glad to have found at least one champion 
to defend the position I have taken against 
an unfounded accusation. 

BroAvn further remarked, that in America 
Drs. Sims and Bozeman almost invariably 
used the scissors for denuding the edges of 
the fistulous opening, which course necessa- 
rily prolonged the 'operation. Dr. Brown, I 
think, is mistaken in his views on this point. 
In regard to sutures, he prefers wire, 
" though," he says, "Dr. Hay ward, inBoston, 
used silk in preference." Why omit to men- 
tion Drs. Sims and Bozeman 1 Brown pre- 
fers silver to the iron wire recommended by 
Dr. Simpson, of Edinburgh, and is in favor 
of giving opium, in order to keep the bow r els 
quiet. He prefers the use of an elastic male 
catheter, to which he attaches a bag. He 
uses two knives, one for the right and one for 
the left hand ; and fourteen kinds of needles. 
He takes great care to avoid wounding the 
mucous membrane of the bladder. " The 
operation is often completed," he says, "in 
ten minutes." (Dr. Brown must be a second 
Bosco.) 

T. 8. Wells, surgeon to the Samaritan Hos- 
pital, in London, has cured several cases by 
the " American method," but, remarkable to 
relate, has arrived at the conclusion that 
fine, strong silk sutures answer even better 
than wire, " because," he says, " they are 
more easily passed, can be used in finer 
needles, cause less irritation of neighboring 
parts, and are removed much more readily, 
while union takes place quite as well as when 
wire is used." Dr. Wells also thinks that the 



40 



!VL SciiUFFERf on Vesieo-Yaginal Fistula. 



use of the catheter is a most troublesome part 
of the after treatment, and believes that it 
might be dispensed with. lie looks upon the 
catheter as a dangerous instrument, citing a 
case which occurred in Brussels, where the 
patient died of Peritonitis, the point of the 
catheter having caused ulceration of the 
bladder. (The remarks of Dr. Wells are too 
prejudiced and partial to deserve a serious 
consideration.) 

The history of the treatment of vesico- 
vaginal fistula in England would be incom- 
plete, if I did not mention an operation per- 
formed by Dr. Gosset, in which he made use 
of the " gilt wire suture." The operation 
Was performed in 1834, and a description of 
it was given in the London Lancet, vol. I, 
page 346. Dr. Gosset says, " Having placed 
the patient resting on her knees and elbows, 
upon a firm table of convenient height, cov- 
ered with a folded blanket, the external parts 
were separated as much as possible by a 
couple of assistants, so as to bring the fistula, 
which was immediately above the neck of the 
bladder, into view. I seized with a hook the 
upper part of the thickened edge of the 
bladder, which surrounded the opening, and 
proceeded with a spear-shaped knife to re- 
move an elliptical portion, which included 
the whole of the callous lip surrounding the 
fistula, the long axis of the ellipsis being 
transversely. This was readily effected ; 
but, in consequence of the very contracted 
state of the parts, the next steps of the ope- 
ration were with difficulty executed ; and I 
should not have succeeded in passing the 
sutures, had I not used needles very much 
curved, and a needle-holder which I could 
disengage at pleasure, the needles being- 
withdrawn with a pair of dissecting forceps 
after the holder was removed. In this way 
three sutures were passed ; and afterwards, 
by twisting the wire, the incised edges were 
brought into contact, and retained in com- 
plete apposition until they had firmly united. 
One of the sutures was removed at the end 
of the ninth day, the second at the end of 



the twelfth day, and the third was allowed 
to remain until three weeks had elapsed. 
After the operation the patient was put to 
bed and desired to lie on her face, an elastic 
gum catheter, having a bladder secured to 
its extremity for the reception of the urine, 
having been introduced and retained by 
means of tapes. She had not the slightest 
discharge of urine through the vagina after 
the operation, which completely succeeded 
in restoring the healthy functions of the 
parts. The advantages of the gilt wire su- 
ture are these : It excites but little irritation, 
and does not appear to induce ulceration with 
the same rapidity as silk or any other mate- 
rial with which I am acquainted ; indeed, it 
produces scarcely any such effect, except 
when the parts brought together are much 
stretched. You can, therefore, keep the 
edges of a wound in close contact for an in- 
definite length of time, by which the chances 
of union are greatly increased. I have used 
it now in very many operations, as after 
extirpation of the breast, tumors of various 
kinds, and for bringing the lips together after 
the removal of a cancerous growth, in all of 
Avhich cases it answered extremely well. In 
the larger operations above mentioned I do 
not, however, particularly recommend it, as 
there is more difficulty in applying it than the 
common suture. It is in minute and delicate 
operations, such as hare-lip, staphyloriaphy, 
and for the closure of fistulous openings, 
where success mainly depends upon a speedy 
union of the parts, that the advantages of 
the gilt wire sutures are most manifest." 
Dr. Simpson, of Edinburgh, enlarges very 
much upon this discovery. "This," he says, 
" is certainly a most extraordinary forestall- 
ing of all that is now being done and said in 
the matter of metallic sutures." " Here you 
have," said Dr. Simpson in a lecture referring 
to this same case, " the position, the wire 
sutures, the mode of introducing them, the 
mode of fixing them, and the after treat- 
ment— in short, the whole operation in all its 
details successfully carried out in England 



M. Schuppert oh Vesica- Vaginal Fistula. 



II 



more than twenty years ago, in the very tame 
way in v Men it has lately been proposed (?) 
to carry it out in America." (But where is 
the bine iron wire, the hollow needle, and 
the iron wire splint } .) 

A3IERKA. 

In this country, Dr.J.P.Mettauer,of Virginia, 

was the first surgeon who operated success- 
fully for the cure of vesico-vaginal fistula, 
An account of the cases treated by him may 
be found in The American Journal of Medi- 
cal Sciences for 1S17. The first of his cases 
was operated upon in 1830. The fistulous 
opening leading to the bladder was of the 
size of a Spanish dollar, and nearly circular. 
Its edges were denuded, and brought to- 
gether with eight sutures of leaden wire ; 
the sutures were carried through the walls 
of the vagina and bladder, and fastened by 
twisting the wire. They were then cut off 
at the entrance of the vagina. The opening 
was perfectly closed, the line of contact of 
the opposing surfaces measuring two inches. 
A short, light silver catheter was permanen- 
tly retained in the bladder. On the third 
and seventh days the wires were tightened, 
and removed on the tenth day. The cure 
was complete and the woman bore two 
children subsequently without any return of 
the injury. In his second case, Dr. Mettauer 
operated eight times, the fistula being dimin- 
ished but not obliterated. In two other 
cases he employed silk ligatures, but did not 
find them to answer so well as the metallic 
sutures. The result of his operations was so 
favorable as to induce him to say: "lam 
decidedly of the opinion that every case of 
vesico-vaginal fistula can be cured, and my 
success justifies the opinion." 

Dr. O. Hayward, of Boston, without being- 
aware of the operations of Dr. Mettauer 
(I quote from Sargent), performed his first 
operation for vesico-vaginal fistula, in 1839 
(vide American Journal of Medical Sciences 
for 1839). Placing his patient as for lithot- 
omy, and etherized, Hayward introduced a 



large bougie of polished whalebone through 
the urethra into the bladder, by means of 
which the posterior wall of the bladder was 
depressed by an assistant, and tints the fis- 
tula came into sight and reach. The margin 
of the orifice was then pared with scissors or 
knife and the mucous membrane of the 
vagina dissected up from its connections to the 
extent of about three lines. This latter step 
was taken in order to gain a larger surface 
for union to take place and partly to obviate 
the necessity or the liabilty of passing the su- 
tures through the bladder. Finally, a needle 
carrying a thread was inserted through the 
mucous membrane of the vagina and the ad- 
jacent cellular tissue, about one-third of an 
inch from the edge of the fistula, carried 
across the latter, and brought out upon the 
opposite side through the mucous mem- 
Inane of the vagina and the cellular tissue, 
at about the same distance from the margin 
of the orifice as that at which it Avas first 
introduced. The sutures were then tied. 
After the operation, the patient was allowed 
to lie upon her side, and a catheter was 
retained in the bladder for a few days ; being- 
removed sufficiently often for cleaning ; but 
later it was only introduced every three 
hours, to remove what urine had accumu- 
lated. Dr. Hayward has operated in this 
manner twenty times on nine different pa- 
tients. On one patient, six times ; on" an- 
other, five times ; on two patients, twice. 
Three were entirely cured, five relieved and 
one was not benefitted. (Boston Medical and 
Surgical Journal for 1851.) 

Dr. F. Marion Sims, of Alabama, contri- 
buted to the American Journal of Medical 
Sciences for January, 1852, a very interesting- 
paper on this subject. Instead of placing 
the patient upon her back, Dr. Sims places 
her upon her knees, the nates being elevated, 
and the head and shoulders depressed ; 
the vagina is then opened and the recto-va- 
ginal septum elevated by means of a "pecu- 
liar lever speculum" held by an assistant. 
Sometimes, where a particularly strong light 



±2 



Mi Schttppert on Yesico-Yagmal Fistula. 



is required, tlie sunlight is reflected from a 
small mirror upon the part to be examined. 
The margin of the fistula is pared as in other 
operations The most distinctive feature in 
Dr. Sims' operations is the kind of sutures 
employed; The thread is of annealed silver 
wire, as fine as horse-hair. The needle is 
held by a forceps and carries a silk thread 
having a loop at one extremity, through 
which the silver wire is passed. The needle 
is introduced at about half an inch from the 
edge of the fistulous opening, pushed deeply 
into the vesico-vaginal septum, without en- 
tering the bladder, however, and brought 
mrt just at the edge of the nmcous lining of 
the latter, at the margin of the fistula ; it is 
then carried across the opening and thrust 
through the vesico-vaginal septum in the 
same manner as before, reappearing at the 
same distance from the edge of the fistula. 
After as many wires are passed as are consid- 
ered requisite, at proper distances from each 
other, they are tightened by damps. Dr. Sims 
terms this suture the " clamp suture.'' 1 A 
solid leaden rod, a little longer than the fis- 
tula, and a line in diameter, or an equally 
small silver tube, perfectly smoothed and 
polished, is perforated at the proper distances 
by holes, through which the silver suture 
wires are passed, and secured either by 
twisting around the bar or by being passed 
through small perforated shot and bent 
firmly over; thus the distal ends of the 
wires are secured. The proximal end of each 
wire is then, in the same manner, passed 
through its approximate hole in another 
similar bar, which is introduced into the 
vagina and placed parallel with the proximal 
margin of the fistula ; the bars are approxi- 
mated as closely as it is deemed advisable — 
not so closely, however, as to superinduce 
strangulation — and the ends of the wire are 
secured as in the first case, and cut off. 

On the third or fourth day after the opera- 
tion, an examination is made to ascertain 
the condition of the parts, and again on the 
sixth or seventh day ; if the sutures are not 



producing any unpleasant effects, they are 
allowed to remain until the ninth or tenth 
day. In order to prevent any injurious ac- 
tion of the urine upon the wound, Sims re- 
tains in the bladder a silver catheter some- 
what of the form of the letter S, and perfo- 
rated with three rows of small holes. The 
recumbent posture is to be strictly main- 
tained, and the catheter is to be worn for at 
least fifteen days, when Sims usually finds 
that the orifice has become pretty firmly 
closed. The bowels are not permitted to be 
moved, and to secure their quiescence opium 
is used as freely as msy be necessary. 

Dr. Sims has since made some alterations 
in his method. He has given up his clamps, 
using only the interrupted silver wire suture ; 
he also places the patient on the left side 
when operated upon. These alterations have 
been made known by Sims in a very curious 
pamphlet, entitled, " Silver Sutures in Sur- 
gery : an anniversary discourse delivered be- 
fore the New York Academy of Sciences, by 
F. Marion Sims, M. D , Surgeon to the Wo- 
men's Hospital in New York, 1858." In that 
discourse (in a language never heard of since 
the days of Bombastus Paracelsus), Sims 
says : "In 1845 I conceived the idea of curing 
vesico-vaginal fistula, and entered upon the 
field of experiment with all the ardor and 
enthusiasm of a devotee. After nearly four 
years of fruitless labor, silver wire was for- 
tunately substituted for silk as a suture, and 
lo ! a new era dawned upon surgery; and •' I 
declare it as my honest and heartfelt convic- 
tion, that silver as a suture is the great 
surgical achievement of the nineteenth cen- 
tury. For my country I claim the honor of 
this imperishable discovery. I will place for 
ever beyond cavil my claims and agency in 
this discovery;" and in his "nowhere ex- 
travagant language," he goes on to say, " I 
shall yet live to see the day when the whole 
profession of the civilized world will accord 
to this simple discovery the high position of 
being the most important contribution as yet 
made to the surgery of the present century. 



M. Schuppert on Yes ieo- Vaginal Fistula. 



43 



The only thing at all comparable to it is 
etherization ; and in practicable results of 
permanent benefit, it is absolutely contempti- 
ble when compared with those arising from 
the universal use of silver sutures in the 
broad domain of general surgery. The next 
eight years will not find an educated physi- 
cian any where "who will dare to use silk su- 
tures.'' " So far as it concerns my experi- 
ence, personal narrative, claims as a discov- 
erer or defense against aggression, I have a 
right to declare them openly from the house- 
tops ;" and "as concentrated efforts have 
been made in various quarters to rob me of 
the full credit for my labors, I have thought 
it due to truth, to justice, to posterity, and 
to myself, to place permantly upon record a 
history of the circumstances attending this 
discovery." " But," says the lunatic Mes- 
sias, who has been sent to resurrect surgery 
from the state of dilapidation into which it 
had fallen, " it was all the result of a provi- 
dential train of circumstances over which I 
had no control, and that it pleased God to 
lead me in this direction, in spite of my 
predilection." 

Purmann, in Breslau, Germany, made use 
of the silver wire in wounds of the tongue, 
as far back as 1740. (Heistei's System of 
Surgery.) 

MiJiles, in his Elements of Surgery, pub- 
lished 1746, employed silver and gold thread 
in the operation of hare-lip. 

Gosset, of London, used gilded wire in 
extenso in 1834, operating for vesieo-vaginal 
fistula, and other surgical diseases. And his 
own countrymen, Le Vert, of Alabama, in his 
experiments on the use of metallic ligatures 
(published in the American Journal of Med- 
ical Sciences, May, 1829), had made use of 
silver and gold, and proved their innoxious- 
ness in animal tissue. If, in the face of such 
indisputable historical facts, the discovery 
of silver sutures can be still claimed " the 
greatest achievement of the nineteenth cen- 
tur}-," Dr. Sims in his claims as a discoverer 
does not seem to be as successful as he has 



been in the use of the metallic wire ; and not 
more successful is he in the discovery of 
"his" other valuable improvements — the 
speculum, the clamp, and the perforated 
shot — the speculum and clamps being al- 
ready used by Metzlar, in Prag, in 1846 (vide 
above history of operation of vesieo-vaginal 
fistula in Germany); and the perforated shot 
in tying the sutures being suggested by Mac- 
lean, in Dublin, and used by Sir P. Orainpton 
and Dr. Cusack in cleft palate, in 1844 (vide 
Braithwaite's Betrospect, part II, page 115). 
But Dr. Sims thinks probably with Goethe, 
" Eur die Lumpen sincl bescheiden" ! 

Br. j\ r . Bozeman, of Montgomery, Alabama, 
published, in 1856, a treatise entitled, " Ee- 
marks on Vesicovaginal Fistula, with an 
account of a new mode of suture, and seven 
successful operations," in which he pointed 
out the objections to Sims' " clamp suture," 
which he considered the essential element of 
Sims' method. He invented a new method, 
and from its construction, mode of action, 
and the circumstances wiiich led to its adop- 
tion, called it the "button suture.'''' The es- 
sential parts of this apparatus consist of 
silver wire for the sutures, a perforated me- 
tallic button or plate, and perforated shot to 
retain the latter in place. The button, says 
Bozeman, "possesses several peculiarities. 
It may be either of lead or silver. The for- 
mer, hammered out to the thickness of one- 
sixteenth of an inch, answers the purpose 
tolerably well. The latter can be made still 
thinner, and does better on several accounts ; 
it is lighter, less likely to yield under pres- 
sure, admits of a higher polish, and allows 
the wires to be drawn through the small 
holes without dragging." " The object of the 
button is to cover the fistulous opening after 
the introduction of the sutures, and its size 
and shape will therefore vary somewhat ac- 
cording to circumstances. The shape of those 
that I usually employ is oval ; but they may 
be circular, semicircular, L or T shaped, to 
suit individual cases. The size will also ne- 
cessarily vary. But whatever the shape cu 



44 



M. Sciiuppert on Vesica- Vaginal Fistula. 



size, it is a matter of great importance that 
the under surface should be slightly concave 
and the edge turned up. Along the middle 
of the button are arranged perforations for 
the reception of the sutures, which should 
be sufficiently large to admit two thicknesses 
of the wire freely. The number of these 
openings will depend of course upon the 
number of the sutures, which are usually 
placed about three-sixteenths of an inch 
apart. Number three shot are used and per- 
forated for the passage of the wires. I gen- 
erally level the edges of the fistula upon the 
vaginal aspect to a greater extent than is 
recommended for the clamp suture. The 
object of this is to obtain large surfaces for 
agglutination, and at the same time to admit 
of a sufficiently firm degree of approximation 
to prevent if possible the least passage of 
urine through the fistulous opening. The 
edges of the fistula having been pared, the 
wire sutures are to be lodged in their re- 
spective places in the usual way, by attach- 
ing them to the ends of silk ligatures previ- 
ously carried by means of a needle through 
the septum from one side of the fistula to the 
other. But in connection with this part of 
the operation, there is some difference be- 
tween Dr. Sims' procedure and my own. In 
the first place, I do not usually take so firm 
a hold of the tissues, the space between the 
entrance of the needle and the edge of the 
fistula rarely, if ever, exceeding half an inch ; 
and it matters not whether the parts be in- 
durated or not, as the wire is not likely to 
cut out very soon. Secondly, it is not neces- 
sary to observe the same scrupulous care in 
entering and bringing out the sutures upon 
any exact line with each other ; for, as will 
be hereafter understood, each one is in its 
action entirely independent of the others. 
Thirdly, instead of being obliged always to 
place the sutures parallel with each other, I 
have it in my power, if the peculiar nature 
of the case requires it, to insert them in any 
direction, and I am thus enabled to bring 
within the sphere of successful treatment a 



large class of cases, which, owing to the ir- 
regular shape of the fistula, and the scarcity 
of tissue not admitting of extensive paring, 
cannot be subjected to the clamp suture. In 
regard to the needle, lam in the habit ot 
using one that is short, straight and spear- 
pointed, in length varying from a half to 
three-fourths of an inch. The needles are 
carried by a needle-holder. The introduction 
of the needle with reference to the structure 
to be penetrated, is justly considered a mat- 
ter of no little importance. Dr. Mettauer 
and some others recommend that the instru- 
ment be carried entirely through the vesico- 
vaginal septum. Drs. Sims and Hayward 
strongly disapprove of this practice, on the 
ground that other fistulas may thus be pro- 
duced, and I fully agree with them. Indeed, 
I consider that too much care cannot be taken 
to avoid piercing the mucous coat of the 
bladder ; and the needles, instead therefore 
of being carried through the septum, should 
be brought out at the edge of the opening 
in the vesical sub-mucous areolar tissue. 
As heretofore mentioned, the wire for each 
suture should be about eighteen inches in 
length, and the sutures shoidd usually be 
placed not more than three-sixteenths of an 
inch apart. Although, if the tissue be suffi- 
ciently abundant to admit of an easy approx- 
imation without too great a strain upon 
them, an interval of one-fourth of an inch 
may be left. The next step in the operation 
is to draw the raw edges closely in contact, by 
bringing the opposite ends of each wire toge- 
ther. This may be readily accomplished with 
an instrument which I have invented for the 
purpose, and called the suture-adjuster. In 
this way the edges of the fistula are gently 
forced together, and for the time being the stiff- 
ness of the wire will prevent their separation. 
A button is now placed upon the wires, its 
concave surface corresponding to the vesico- 
vaginal septum, and carried down in contact 
with the septum. The wires being again held 
in the left hand, the button should be pressed 
gently against and adapted to the surface of 



M. SciiCPpr.KT on Vesieo-Vaginal Fistula. 



the parts. The shot are now passed down 
over the approximated ends of each suture 
to the convex surface of the button, and here 
each one is successively grasped with a pair 
of strong- forceps and held against the button, 
while traction is made upon the correspond- 
ing suture, in order to bring the vaginal sur- 
face of the septum in close contact Avith the 
concave surface of the button, and insure 
close adaptation of the edges of the fistula. 
This having been satisfactorily aceomidish- 
ed, sufficient force is exerted upon the forceps 
to compress the shot and thus prevent its 
slipping. The operation is then concluded 
by clipping off the wires close to the shot. 
The apparatus is generally allowed to remain 
on not more than ten days." 

Bozeman says, in his pamphlet, " by means 
of the button suture, quietude and an accu- 
racy of approximation are secured, to a 
greater degree than by any apparatus that 
has ever before been invented, two circum- 
stances upon which the cure of fistulas often- 
times solely depend. But probably one of 
the most important advantages of the button 
suture is the protection that it affords to the 
denuded edges of the fistula against the poi- 
sonous influence of the urine in case of dou- 
ble fistula. Leucorrhoeal discharges are also 
more or less harmful." 

I have given here the method of Bozeman 
with minuteness. The success he and others 
have had with it is known, but it may not be 
without interest to look to what it has been 
reduced. 

Sims says, "Bozeman has mistaken the 
philosophy of the suture ; his button is an 
unnecessary addendum. When the button 
was to be applied, I found it had to be 
convex instead of concave, as so particularly 
recommended by Dr. Bozeman." Dr. J. B. 
Brown, of London, has cut the button in 
as many pieces as he applied sutures. Dr. 
Simpson, of Edinburgh, who operated on 
one case according to Bozeman's plan, says, 
" The operation did not succeed, and I 
should not be inclined to repeat it ;" he in- 



vented his open wire splint, instead of the 
button, "preventing thereby the included 
portion of the vesico-vaginal septum from 
being moved either longitudinally or trans- 
versely" — a condition which he" thinks is 
absolutely necessary to form a perfect union, 
asserting that in Bozeman's button no pro- 
vision was made against the movements 
which were produced in the surrounding 
parts and lips of the fistula by the spasmodic 
working of the muscular wall of the bladder. 
Dr. D. H. Agnew, of Philadelphia, has also 
thought fit to alter the button. His substi- 
tuted lead button has only a centre-piece 
with holes, through which to pass the su 
tures, and between this centre-piece and the 
circumference on either side two half-moon 
pieces are cut out. He reports a successful 
case obtained through its use, saying, " Had 
I not adopted this button I feel satisfied 
failure must have ensued, as I was obliged 
to press back in two places small portions of 
the mucous membrane of the bladder, which 
had worked down between the approximated 
edges of the wound, and which were easily 
discovered through the apertures cut in the 
button." 

What alterations next :f . The button suc- 
cessfully reverted, cut in pieces and broken 
through, being now stripped of its most es- 
sential character, will eventually be so modi- 
fied as that nothing will be left but the holes. 
Such is the irresistible power of progress. 
Just as Sims had to relinquish his clamp, so 
will Bozeman seal his button to the tomb of 
the Capulets, and that too with no abatement 
of his former success in operating. 

There can be no doubt but that the pro- 
gress so lately made in the operation for the 
cure of vesico-vaginal fistula is mainly due to 
the exertions of Sims and Bozeman, in this 
country ; to the application of a proper spe- 
culum to get easy access to the fistulas, and 
the use of metallic sutures, and Ave may safe- 
ly assert that since in the tAvo cities of New- 
York and New Orleans more cures of that 
loathsome disease have been accomplished 



4(> 



M. SciiliPPERT on Vesico-Vaginal Fistula. 



than in the whole of Europe. This should 
be sufficient to recommend the system to 
which Verneuil, of Paris, has so graciously 
given the name of the American method. 
But what shall we say when we find an 
American surgeon at so late a date as 1858, 
in his "Lectures on Surgery," say, "Attempts 
to cure this affection by the use of sutures, 
have so generally failed that it is unnecessary 
to do more than allude in general terms to 
the method in which these operations are 
performed;" and "the autoplastic opera- 
tions of Mr. Jobert, in Paris, furnish the 
most hopeful resource," and again " of the 
several methods proposed for the cure of this 
melancholy accident, not one can be relied on." 
Indeed there is something more melancholy in 
such a lecture than the melancholv accident ! 



In the preceding pages I have attempted 
to give a general view of the historical 
records of the operation for the cure of vesico- 
vaginal fistula. I am not conscious of having 
omitted any method or proposition possess- 
ing any intrinsic value. That I have not 
mentioned all the different methods concern- 
ing which we know no more, than the asser- 
tion of the author, that by xxsing his method, 
" the most terrible cases may now be treated 
with a certainty of success not heretofore 
attainable," I hope I may be excused. 

In speaking of my own vieAvs and opera- 
tions, if I look upon what others have accom- 
plished, I feel that my own labors do not 
amount to much. Error is the common lot 
of mankind ; where I have committed errors, 
let others correct them. 



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